26 February 2019 , Thiruvananthapuram

1. First 1000 days - Need multi-sectoral approach in ECD 26 February 2019, Thiruvananthapuram Job Zachariah, Chief, UNICEF Office for Kerala & Tamil Nadu Mob: 98407-65825 / email: jzachariah@unicef.org

2. First 1000 days • First 1000 days from conception to first 2 years (270 days in womb + 365 in first year + 365 days in 2nd year) is most critical period of a person’s life. • It makes or breaks life of a person. • First 1000 days decides health, death, nutritional status, height, school performance, earning, happiness & even behaviour of a person. • It lays foundation of social, human & economic development of child, individual, family, society & country. • Window of opportunity closes after first 1000 days. Damage/loss caused in first 1000 days is irreversible

3. First 1000 days: What it decide/influence First 1000 days decide/ influence: • Child mortality: 50% death of under-5 children happens in first one year • Child malnutrition/stunting- mostly take place in first 1000 days (Lancet,2013) • Illness in childhood & heart diseases, hypertension in adult life (Lancet,2008) • Height of individual in adulthood • Intelligence (IQ), school attendance & school performance (Lancet, 2007 ) • Cognitive, emotional & social development of child. • Behaviour and attitude of individual • Happiness and success in life • Earning capacity of individuals at adult life (Grantham-McGregor,2007 ) • Man-days lost, production, productivity & GDP of country (WHO,2004) • Destiny of a person and country is written in the first 1000 days of life • Why is knowledge on first 1000 days low?

4. What needed in 1000 days-21 interventions • 21 interventions identified from Lancet/WHO/UNICEF studies • Most interventions around practices/behaviour at individual/family level. • Out of 21, 10 interventions are to be provided for children, 4 for mothers, 3 for adolescent girls and 4 by all. • Only a few interventions need medicine or hospital support. • Social determinants like girls education, child marriage, food security, social protection, water and sanitation etc plays a powerful role in first 1000 days

5. 21 Interventions in first 1000 days • Ensure full 5 immunization of infant before the first birthday • Ensure 9 doses of vitamin-A for under-5 children - twice in a year • Reduce anaemia of pregnant women by iron rich food/IFA tablets • Improve maternal nutrition and intake of nutritious food & micronutrients • Ensure rest, care & health checkup of pregnant women • Reduce pre-term birth & low birth weight • Ensure better neo- natal care • Prevent & treat birth defects and congenital heart disease • Prevent/ treat diseases among children, especially pneumonia, diarrhoea and worm infestation • Initiate breastfeeding with in 1 hour of birth of the baby • Ensure exclusive breastfeeding of babies for the first 6 months

6. 21 Interventions in first 1000 days • Begin complementary feeding from the 7th month, with continued breastfeeding until 2 years • Prevent malnutrition/stunting among children • Use iodized salt • Early stimulation & early childhood development in first 1000 days • Use of toilet by all • Drink safe drinking water by all • Wash hands with soap before eating food and after going to toilet • Improve adolescent health and reduce anaemia among adolescents • End child marriage of girls below 18 years • Ensure education of all girls up to 18 years

7. 1. Ensure full 5 immunization of infants before first birthday • 38% children ( over 80 lakh)in India do not get all 5 vaccines in first year (NFHS-4). • An infant should get 5 vaccinations before first birth day - at birth, 6 weeks, 10 weeks, 14 weeks and 9 months. • Immunization (health/survival) is the right of the child, as per UN convention on rights of the child (CRC). Denying vaccination is violation of child rights. • Opinion/belief of parents cannot be imposed on children, if it violates child rights on health & survival. • With introduction of new vaccines like rotavirus vaccine (diarrhoea) & pneumococcal vaccine (pneumonia), more child deaths could be prevented.

8. Benefits of Immunization • 17% of child deaths are vaccine preventable (WHO,2014). • Vaccination protects children against 14 diseases - polio, tuberculosis, measles, diphtheria, whopping cough, tetanus, hepatitis-b, mumps, rubella, brain fever (Japanese encephalitis), vitamin-A deficiency, and also Hib virus associated pneumonia, meningitis and otitis (middle ear infection). • Immunization is the safest & most cost effective health intervention available in world to protect children form death and disability

9. 2. Ensure 9 doses of Vitamin A for children below 5 years • 40% children (50 million) of 6-59 months do not receive Vitamin-A dose India (NFHS-4). • Vitamin-A to be given 9 times- 9th month & every 6 months up to 5 years • Vitamin-A supplementation can reduce all-cause child mortality by 24% (WHO,2008) • Devta study in India showed child mortality reduction of 11% by Vitamin-A supplementation. • Vitamin-A deficiency alone responsible for 8% of child deaths in south east Asia (WHO,2009) • Vitamin-A given in campaign mode in all states, as in polio. Not in Kerala.

10. 3. Anaemia – What & Prevalence What:Anaemia is caused by lack of nutrients like iron & folic acid in blood; or lack of blood; or decrease in red blood cells/ hemoglobin in blood. Anaemia leads to poor ability of blood to carry oxygen to parts of body. Minimum Hb: Minimum level of hemoglobin (Hb) (NIN, 2014): • 11 grams - pregnant women/ pre-school children; • 11.5 grams- children of 5-11 years; • 12 grams - women/ adolescents/ lactating women; • 13 grams- adult men. Prevalence: More than half (53%) of women and adolescent girls in India are anaemic (DLHS 4). • About 20 crore women of 15-49 years in India are anaemic.

11. Anaemia – Consequences • Consequences of anaemia are: • 20% of maternal mortality (Robert, Lancet 2008) • Infant mortality due to preterm baby, low birth weight & poor fetal growth. • One unit Hbincrease leads to 24% decrease in child death (Samuel P Scott,2014) • Malnutrition and stunting among children • Diseases- Global burden of disease due to deficiency of iron/iodine/ vitamin- A is 10% (World Bank, 2002). 2.4% disease burden (Murray & Lopez,1996) • GDP loss – About 4% GDP loss(Horton,2003) . Combined economic loss –5% of GDP (World Bank,1994)

12. 4. Improve maternal nutrition Maternal stunting • Maternal stunting (height less than 145 cm/ 4 feet 9 inches) & low maternal BMI affects fetal growth of baby, leading to low birth weight, pre-term delivery & death of babies. • Every 1 cm of maternal height is associated with increase of 1/2 cm height in adult offspring(Lancet 2008, Cesar G Victora et al). Protein • Energy protein supplementation reduces incidence of small for gestational age (SGA) by 32% & risk of still births by 45% (Cochrane review,2003) . Supplementation • Mothers needs zinc supplementation (reduce pre-term births by14%); vitamin-A(prevent night blindness, low birth weight &infant mortality ; & folate (reduce neural tube defects & congenital malformations). • Also needs calcium(reduce risk of gestational hypertension by 35%, pre-eclampsia by 55%, pre-term birth by 24% and low birth weight); &vitamin-D supplementation (prevent pre-eclampsia)- Lancet, 2013

13. 5. Ensure rest, care & Health check-up of pregnant women • A pregnant woman needs rest & at least 5 ante-natal checkup. • Only one-fifth (21%) of mothers in India receive full antenatal checkup (4 ANC+ 1 TT+100 IFA tablets) during pregnancy (NFHS-4). • Social practice of “puliyoonu” in Kerala signifies importance of rest, care & nutritious food for pregnant women. It should be promoted. • Universal maternity benefit

14. 6a. Reduce LBW • 13% of babies ( 65,000 out of 5 lakh born every year) in Kerala are born with low birth weight less than 2500 grams (RSOC 2013-14). • Low birth babies are 40 times more likely to die & very low birth babies (less than 1500 grams) are 200 times more likely to die in neo-natal period (New England Journal of Medicine). • Major causes of low birth of babies are: pre-term delivery & maternal anaemia, lack of prenatal care maternal sickness & unhygienic home environment. (Andrew, K.M et al, 2008) • Association between fetal growth restriction (FGR) & infant survival reported in many studies (Regev RH,2004; and Pulvert,2009). • Fetal growth restriction due to maternal undernutrition leads to 12% of child deaths; 20% of childhood stunting; & low psycho-motor development of children (Lancet, maternal & child nutrition series, 2013).

15. 6b. Reduce Pre-term delivery • Pre-term births account for 35% of total neonatal deaths (Lancet) • Pre-term & small for gestational age (SGA) babies are at a higher risk of neonatal mortality, post-neonatal mortality, stunting, & long-term neuro-developmental impairment (INAP, 2014 & Lancet, 2013) • Both pre-term deliveries & low birth weight of children can be prevented by: a) improving maternal nutrition; and b) ANC care, nutritious food & health check-up for pregnant women • LBW & pre-term babies may need Special New-born Care Unit (SCNUs). SNCUs in 10 district hospitals in state.

16. 7. Ensure better neo-natal care • 2/3rd of infant deaths happen in first 28 days (neo-natal period). 40% of still births & neonatal deaths take place during labour and on the day of birth (INAP, 2014). Death of babies on first day and in first month of birth can be prevented. • In Kerala, about 3,000 infants die before 28 days every year. Causes of neonatal death • Major causes of neonatal deaths are: preterm birth complications-35%, birth asphyxia-20%, sepsis /tetanus- 15%, pneumonia - 16%, malformation -9%, others -3% and diarrhoea- 2% (Liu L. et al., statistical report of 2012 & 2010, Lancet) . • But in Kerala, congenital anomalies-28% is a major cause of neonatal death, along with pre-term birth-35% (IAP study, 2012)

17. Neo-natal care- What can be done • Magic bullet to prevent neo-natal deaths- initiate breastfeeding within one hour and exclusive breastfeeding. Breastfeeding can prevent all-cause neo-natal mortality by 55%-87%(Gary L Darmstadt et al, Lancet 2005) • Second best strategy is “kangaroo mother care” method or skin to skin contact between mother and baby at birth and after. This practice will reduce 40% of neonatal mortality, 58% of sepsis and 77% of hypothermia (Cochrane review, Conde- Agudelo A, 2011). • Child care practices like immediate drying of baby, covering head & feet & delayed bathing of baby (after seven days) will prevent hypothermia & death, especially in pre-term and low birth babies (INAP 2014). • Delayed cord clamping and chord care can prevent neonatal deaths.

18. 8. Prevent and treat CHD • 5,000 children die every year in Kerala before their first birth day. Out of this, about 1,500 died due to congenital heart disease (CHD) before “Hridyam” started. • India need at least 130-260 centres for CHD surgery/treatment facility. Kerala set an example with 6-8 centres for Hridyam. • Diagnose congenital anomalies at time of birth/conception stage & then CHD surgery can prevent infant deaths. • About 6-7% of babies have birth defects(March Dimes, 2006) & 10% have development delays(MH&FW, 2013).

19. 9. Prevent/treat diseases - pneumonia, diarrhea, worm infestations • Pneumonia, diarrhoea & malaria together cause more than one-third (36%) of under-five child deaths in India. • These diseases can be prevented/treated and thereby prevent death & child malnutrition. • Children with diarrhoea should be provided ORS & Zinc. • Handwashing with soap before eating food and after going to toilet can prevent 50% of diarrhoeal episodes & 25% of respiratory disease episodes among children (Curtis and Cairncross, 2003). • Handwashing with soap alone can prevent about 15% of child deaths.

20. 10. Initiate Breastfeeding in 1 hour of birth, placing newborn skin-to-skin with mothers • Breastfeeding within one hour will prevent 22% of all neo-natal deaths(Ghana study, 2006). Risk of death in first 28 days of birth is 41% higher for babies who are initiated breastfeeding after 2 hours( Lancet Globe Health, 2016). • Only 42% mothers in India breastfeed within one hour (NFHS-4),although all deliveries are in hospitals. • About 36% of deliveries in Kerala are through C- Section (NFHS-4) & often mother’s milk is not given within one hour in C-section deliveries. • Some hospitals separate newborns from mothers and keep them in separate nurseries, which is not a good practice. • As per Infant and Milk Substitute Act, a health worker can distribute infant milk substitute to a mother, only if mother cannot resort to breastfeeding. Mothers need support • Breast feeding is not a one woman job (UNICEF, 2016). • Mothers need support of family including father & husband (encouragement), nurses (lactation counselling), workplace (leave, nursing break, crèche facility), hospitals (promotion of breast feeding) & government (for legislation).

21. Breast milk: Mothers make medicine • As per latest evidence, mothers produce germ fighting milk for infants. This is called “backwash breastfeeding”. • When babies have infection, they produce pathogens, which are detected by mother through saliva of baby. Mother then produce antibodies to fight them (Gura,T, 2014), and provide it through breastmilk. • Mothers share their immune system with baby, by transmitting good bacteria of micro-biota and micro-biome to infants through breast milk. This helps infant to fight diseases and to digest food & strengthen immune system of baby(UNICEF, From the first hour of life, 2016)

22. 11. Ensure exclusive breastfeeding in first 6 months • Only half (55%) mothers in India breastfeed babies exclusively on mothers milk for first 6 months (NFHS-4). • Often, mothers give formula & products from 4th month, thinking that newborns need more than breastmilk. It is a myth. Evidence shows that food introduced before 6 months add no growth advantage(Dewey, K.G.,2001). • Some give water to babies of less than 6 months during summer. This is not needed. Consequence of sub-optimal breastfeeding • Breastfeeding within hour and exclusive breastfeeding for 6 months will prevent 13% of under-5 deaths (Gareth Jones, Lancet, 2003 ). Lancet 2013 attributes 12% of child deaths to sub-optimum breastfeeding. • Breastfeeding can prevent all-cause neonatal mortality by 55%-87% (Gary L Darmstadt et al, Lancet 2005). Infants who received food & liquids in first 6 months are 2.8 times more likely to die(Sankar, M.J., et al., 2015). • Low rate of breast feeding leads to economic loss of $ 300 billion for Global economy (Rollins, B., Lancet, 2016). Equivalent to Rs 10,000 crore loss for Kerala

23. Mothers - Benefits of breastfeeding • Do you want to shed the excess weight gained during pregnancy? Then, breastfeed babies. Breastfeeding mothers would shed their extra weight at a faster pace and can regain their shape quickly (various studies). • Breastfeeding minimises risk of breast cancer, ovarian cancer, type-2 diabetes, & osteoporosis among mothers. • It reduces bleeding after delivery & helps mothers to recover fast. • Breastfeeding acts like a contraceptive & delays ovulation and next pregnancy (Chowdhry, R., et al., 2015). • It strengthens bonding between mother and baby.

24. Babies - Benefits of breastfeeding • Breastfeeding reduces death, diseases and malnutrition among children. • Breastfeeding could prevent 13% of death of children under-5 years (Lancet). • Do you want your baby to be smart and healthy? If yes, breastfeed them. According to studies, breast-fed babies have 5-8 IQ points more than bottle-fed babies. • Breast milk is critical for brain development & emotional & motor development of infants. • Breast-fed infants are less likely to have infections as it prevent one third of respiratory infections episodes, and prevent half of pneumonia episodes (Victora, C.G, Lancet, 2016). • Prevents acute otitis media (ear infection reduced by 43%), dental caries & intestinal illnesses. • Breast-fed infants are less likely to have chronic conditions like diabetes, heart diseases, asthma and cancer later in their life. • Breast-milk is a magic food which provides many benefits to children, besides preventing death and malnutrition among children. • Colostrum, first milk of mother, is the best vaccination & medicine for baby at birth. It contains antibodies that protect babies against infections, pathogens & allergens • Breast-milk contains ideal balance of nutrients that infants can easily digest.

25. Baby Friendly Hospitals – Where are they? • Kerala was the first state declared as “baby friendly hospital state” in world in August 2002 under UNICEF-WHO program of Baby friendly hospital initiative (BFHI) (Hindu and Times of India, 1 August, 2002). • In 1995, Kochi City became first baby friendly hospital city in India. • BFHI, launched globally in 1991 by UNICEF and WHO, promoted 10 practices to promote breastfeeding. • Although Kerala was a pioneer in promoting breastfeeding in hospitals , the practice has slipped back in last few years.

26. 12. Begin complementary feeding from 7th month • Complementary feeding with adequate diet is only 10% in India(NFHS-4). • Most infants initiated to complementary feeding from 7th month in state. More awareness needed on quality/food diversity/frequency of complementary food. • Social practice of ‘choroonu’ needs to be promoted for highlighting quality of complementary feeding. Continued breastfeeding until 2 years • Breastfeeding beyond 12 months prevent half of child deaths in 12-23 months (Victora, C.G, Lancet, 2016);leads to higher performance in IQ test & better productivity. • Longer periods of breastfeeding may reduce child’s risk of obesity(Victora, Lancet)

27. 13. Prevent Malnutrition/stunting • Malnutrition & stunting among children, are important indicators showing development status of a country. • Almost all stunting takes place in first 1000 days (Lancet, 2013). • 38% of children below 5 years in India are stunted (NFHS-4). • Malnutrition rate in developed countries: USA- 1%; Tunisia & Turkey -2%, Singapore & Morocco-3%, China/Peru/Romania-4% (UNICEF, SOWC Report, 2014). • What decides the height of a person - Hereditary factors/race or nutrition/sanitation/environmental factors?

28. Malnutrition - Consequences Consequences of stunting/malnutrition are irreversible and lifelong. • Child mortality: Root cause of 45% of deaths of children below 5 years is under-nutrition, deficiencies of vitamin-A and zinc, sub-optimal breastfeeding & fetal growth restriction (Robert E Black, Lancet maternal & child nutrition series, 2013). • Child deaths: Stunting & underweight each account for 17% of child deaths and wasting for 11.5% of child deaths (Lancet, 2013). • Diseases:Undernutrition of children increases risk of death from infectious diseases; & increased hazards of death from diahorrea, pneumonia & measles (Lancet, 2013). A stunted person has increased risk of chronic diseases, obesity, diabetes, & hypertension. • Loss of IQ: Stunting in children leads to poor cognitive development & educational outcome, & reduced activity and play (Lancet, 2013). Malnutrition reduces a child’s IQ by 10-15 points (Various studies). Stunting at 12-36 months leads to lower performance in school (Lancet, 2007). • Loss of income: Stunted children could lose up to 22% of their adult income (Grantham-Mc Gregor, 2007) . 1% increase in a person’s height is equal to 2.4% increase in wages (Brazil study, 1997). • GDP loss: A country could lose 6% of its GDP due to malnutrition (WHO, 2004), mainly due to low productivity of stunted persons and man-days lost due to diseases.

29. Myths on Malnutrition. Is it only in Attapady? • One myth is that main cause of undernutrition is poverty & food insecurity. But data from many countries shows that lack of food & poverty are not main causes of undernutrition, except during famine & emergencies (World Bank, 2006). • Food supplies are relevant, but other factors like feeding & caring practices of young children, access to health services and water & sanitation play more important role in addressing malnutrition (Pelletier and others, 1995) • There is undernutrition even in regions/households with plentiful food (various studies). Among the rich in India, 26 % of pre-school children are underweight and 64 % anemic (World Bank, 2006). • Another myth is malnutrition can be improved only by economic development & poverty reduction. Although nutrition level improves with economic development, most effective way to reduce malnutrition is by promoting feeding practices, sanitation & hygiene & care of pregnant women.

30. Malnutrition - Causes Under-nutritionismainly caused by: (UNICEF Framework, SOWC, 1998) • poor practices on breastfeeding, complementary feeding & child care practices; • Inadequate/inappropriate dietary intake including micronutrients; • diseases and worm infestation among children; • maternal under-nutrition, maternal/adolescent anaemia and low BMI, resulting fetal growth restriction, low birth weight & pre-term delivery; • unsafe water, poor sanitation; poor hygiene like handwashing with soap . • poor access to health facilities • root causes include poverty, food insecurity and illiteracy EE • A major cause of child stunting is subclinical disorder of small intestine referred to as “environmental enteropathy-EE”. EE leads to shortened villi and malabsorption. EE can be prevented by stopping in-take of human and animal feces by infants and young children (Jean Humphrey, 2013). • Chicken in a dirty environment grows poorly (UNICEF SOWC Report, 1998).

31. SAM - Treatment and prevention • 7.5% of children below 5 years have severe acute malnutrition (SAM) in India (NFHS-4). • SAM- major cause for child mortality • SAM children may need timely & therapeutic feeding & care. • SAM children can be identified by: a) using MUAC (Mid-Upper Arm Circumference) tape; b) by checking weight as per height; & c) examining for bi-pedal edema. • SAM children with medical complication may need special care in NRC (Nutrition Rehabilitation Centre).

32. 14. Use of Iodized Salt • 93% of HH in India use adequately iodized salt (NFHS-4). • A person needs only one teaspoon (5 milli-litre) of iodine during life time, or 100-150 micro gram of iodine daily. • Iodine is a micro-nutrient essential for body growth and brain development. • Iodine deficiency leads to goiter, cretinism, abortion, still birth & birth defects. It causes speech & hearing defects, squint, psychometric defects & mental retardation. • Iodine deficiency can cause loss of 13 IQ points among children, leading to poor school performance, repetition, absenteeism & drop-out. • Even mild iodine deficiency in pregnant women affects foetal brain. • Infant & prenatal mortality can be reduced by preventing iodine deficiency during pregnancy. • In India, only iodized salt can be sold for human consumption, as per Food Safety Act. In some rural areas , crystal salt is used, often not adequately iodized.

33. 15. Do early stimulation in first 1000 days • Facebook founder Mark Zuckerberg in Dec 2015 posted picture in Facebook showing him reading a book on quantum physics to his one-week old daughter. • Cognitive, language, sensory, emotional & social development mostly take place in first 1000 days of child. • In first 1000 days, brain cells grow at a speed making 700-1000 neural connections per second (E.I. Knudsen, 2004). These connections build brain architecture & lay foundation for later learning, behaviour & health (Harvard University Centre on Developing Child). • These connections are the building blocks of a child’s life and are deeply affected by genetics & early experience/exposure of baby. What is going inside a tiny brain is nothing short of rocket science (Prof. Patricia Kuhl)

34. 15. Early stimulation in first 1000 days • Early years defines her capacity to learn, school performance, behaviour, attitude in adult life, success in work place & community & even her happiness in life. Reading to infants improve their vocabulary and reading skills, even if they don’t understand • When we stimulate a child’s mind by playing with her, talking to her, and reading to her, we feed her developing brain. When we nourish a child’s body with the proper nutrition, we are also feeding her brain and facilitating those neural connections. • And when we protect her from violence and abuse, we are also buffering her brain from the toxic stress that can break those critical connections and hamper healthy brain development(Anthony Lake, 2014). • Experiences and exposure of infants in early years can have lasting impact on success in later life and school performance. By age 3, children of college educated parents had vocabularies 2-3 times higher than parent’s who had not completed high school (Hart B & Risley T, 1995). • Early experience determines physical health at adulthood. Adults who recalled 7 or 8 adverse experiences in childhood are 3 times more likely to have cardio vascular diseases as an adult (Dong et al, 2004).

35. 16. Use of toilet by all • GDP loss due to poor sanitation is 6.4% of a country (WSP 2010; World Bank 2006). • Strong correlation between open defecation & height of children (Esrey, 1996; and Dean Spears, 2012a). Open defecation accounts for much of excess stunting in India (Dean Spears, 2012) • Swachh Bharat Mission aims to make India open defecation free(ODF) by 2019. • One gram of human feces contains 1000 billion crore (one lakh crore) viruses and bacteria. (Globalhandwashing.org) • One person releases 300 grams of feces every day containing billions of bacteria and viruses. • Open defecation leads to diseases/low productivity/GDP loss/ stunting. • Even if one person defecates in the open in village, it will affect all. • Stop the practice of disposing feces of babies in open. • Animal feces also has virus & bacteria and therefore contamination with food or water should be prevented.

36. 17. Drink safe drinking water • Access to safe drinking water -76% in India (Census, 2011). • Drink only treated tap water, boiled or chlorinated water. Open & unprotected wells have to be bleached by bleaching powder regularly. • Unsafe drinking water, poor hygiene practices and lack of access to sanitation together contribute to 88% of deaths from diarrheal diseases.(World Bank, 2008)

37. 18. Wash hands with soap before eating food & after going to toilet • Wash hands before eating food and after defecation, as hands are carriers of diseases carrying pathogens • A dirty hand contains 10 crore viruses and bacteria, which causes diseases among children and leads to malnutrition and death of children. • In India, only 53% wash their hands with soap after defecation and only 38% do so before eating food(Indian Public health Association, 2008). • All soaps effective in removing germs. Regular soap is as good as anti-bacterial soap. • Handwashing with soap can prevent 40% of diahorreal diseases & 30% of respiratory diseases including pneumonia, major killers of children (Curtis& Cairncross, 2003). • It also prevents typhoid, worm infestation, jaundice, and skin & eye infections. • Handwashing with soap by birth attendants and mothers can reduce neonatal mortality up to 41%(www.ncbi.nlm.nih.gov/pmc/articles).

38. 19. Improve Adolescent Health & reduce anaemia • Second window of opportunity • Adolescent health is critical for maternal nutrition. Adolescence is a period of rapid growth & it helps to catch up with stunting from childhood (Prentice AM, 2013). • One-third (31.3%) of adolescent girls of 10-19 years in Kerala anaemic (DLHS-4). • BMI of adolescent girls of 15-18 years lower than 18.5 in state, is 34.8%, showing one-third girls are underweight (RSOC, 2013-14). • Pregnancy in adolescents should be avoided, due to higher risk of complications & mortality in mothers (UNICEF, 2008). Pregnancy in adolescents will slow & stunt a girl’s growth (Gigante DP, 2005 and Rah JH, 2008). • Other adolescent health issues are:sexual and reproductive health, menstrual hygiene, mental health, gender based violence, non-communicable diseases & substance abuse relating to alcohol, drugs & tobacco.

39. Anaemia: Consequences for adolescent girls • Anaemia could reduce IQ of anemic child by 5-10 points (WHO,2001)& IQ reduction due to iron deficiency anaemia is 8 points (Seshadri & Golpadas, 1989) . • Anaemic adolescents cannot concentrate well in studies & perform poor in examinations, leading to drop-out & early marriage of girls. • Menarche of anemic girls could become irregular. • A girl can improve her skin complexion & glow of her face by adequate iron intake. • Anaemia also causes tiredness, dizziness, & breathlessness among adolescents, affecting quality of life.

40. 20. End Child Marriage of girls below 18 years What is the correlation between child marriage & health of children/women? • 27% of girls in India are married before 18 years (RSOC 2013-14). About 30-35 lakh child marriages in India every year. • Child marriage of girls could lead to maternal and infant mortality, malnutrition of children, school drop-out of girls and violence against girls. • Child marriage is gross violation of human rights & child’s right to education, health, nutrition & protection. It is the worst form of sexual abuse & exploitation and deprives children of childhood (UNICEF, 2001).

41. Child Marriage - Consequences • Maternal mortality: Girls under 15 years are 5 times more likely and girls aged 15-19 are twice more likely to die in child birth (UNICEF, 2009 and 2011). Teenage mothers have higher risk of eclampsia, pre-eclampsia, hypertensive disorder & post-partum hemorrhage, major causes of maternal deaths(Lancet, 2011) • Child marriage pushes girls into vicious syndrome of early pregnancy, major cause for high maternal & infant mortality & inter-generational cycle of malnutrition (Ministry of WCD, 2009). • Health problems: Child marriage increases risks of cervical cancer and urinary fistula. • Infant mortality: Infants of child brides are 60% more likely to die before first birthday than children of mothers who are over 19 years (UNICEF, State of the World’s Children, 2009) • Women married before 18 years are likely to have more children (UNICEF, 2005) • Under-nutrition: Children of under-age mothers are likely to be of low-birth weight, causing under-nutrition & delayed physical and cognitive development (UNICEF, State of World’s Children, 2009) • HIV: Child brides are at greater risk of contracting HIV & sexually transmitted diseases (Girls not Brides, 2011) • School drop-out: Child marriage compels girls to drop out of school, resulting in inequality and limited decision-making power at home. • Poverty: Lack of schooling and income opportunities pushes girls to lowly paid jobs and to poverty, to which women are more vulnerable. • Violence and abuse: Girls married before 18 years in India are twice likely to be beaten and threatened by their husbands (USAID, 2007)

42. 21. Ensure education of girls up to 18 years • Magic bullet for social and human development is girl’s education up to 18 years. • Gross enrolment ratio (GER) of girls in India in class 9-10 is 81% and class 11-12 is 56% (U-DISE, 2015-16).. • Education of girls will prevent child marriage and child labour; reduce IMR, MMR, aneamia & child malnutrition; lead to higher production, earning & economic development • Parental education is an important variable in cognitive & emotional development of children, besides prevention of diseases, death and malnutrition among children. • One year of schooling will increase GDP by 10% (various studies) • Strong correlation between child health indicators and maternal education.

43. Other social determinants of child health • Agriculture and food security; • Social protection and safety nets • Maternal mental health • Women empowerment • Child protection • Family planning

44. Programs- Multi-sectoral approach needed. Ensure education of girls up to 18 years • MAA • AMB • WIFS • RBSK • RMNCH+ • ICDS • Swatch Bharat • Swajal • NRDWP • BBBP • SSA • RKSK • Program for Adolescents • And so on

45. Thank You I can do things you cannot You can do things I cannot But, together, we can do great things - Mother Teresa