Monitoring and Evaluation of

Maternal and Child Nutrition

Session Objectives

By the end of this session participants will be able to:

Apply basic M&E concepts to maternal and child nutrition
interventions
Design and use M&E frameworks for nutrition programs
Identify nutrition interventions and common indicators for
assessing their results
Describe M&E challenges of nutrition programs
Session Overview

Defining malnutrition
The problem of malnutrition
Interventions and strategies
M&E frameworks for nutrition programs
Common indicators & data sources
M&E challenges
Defining Malnutrition
Malnutrition: generic term includes both undernutrition and
overnutrition
Undernutrition: is insufficient consumption to maintain good
health caused by (any or all)
insufficient food
poor quality diet
disease
Undernutrition can lead to impaired growth, weak immune
function and death if not treated
Defining Malnutrition

Overnutrition is the excess consumption of food, which can

lead to obesity and chronic diseases such as heart disease
and diabetes.
Most nutrition programs in developing countries have
targeted undernutrition, which is the focus of this module.
However, many countries are beginning to experience dual
malnutrition epidemics with high levels of both undernutrition
and overnutrition.
The Problem
Maternal and child undernutrition is the underlying cause of
3.5 million deaths, 35% of the disease burden in children
younger than 5, larger than any other risk category.
20% of children younger than 5 years in low- and middle-
income countries are underweight (low weight for age).
32% were stunted (low height for age).
The Problem
Among micronutrient deficiencies, the largest disease
burdens among children under 5 are attributed to vitamin
A and zinc.
Iron deficiency anemia is highly prevalent (est. ~25% of
pregnant women) and a risk factor for maternal mortality.
Iodine deficiency is the primary cause of preventable
mental retardation in children and is associated with
miscarriage, stillbirths and infant mortality.
How
Maternal
and Child
Nutrition
are Linked
 Short-term Long term consequences:
consequences: adult size, intellectual ability, economic
Conceptual productivity, reproductive performance,
Framework Mortality, morbidity
metabolic, cardiovascular disease
Causes of
Malnutrition Nutritional Status

Immediate
Feeding practices Health Causes

Household Care of mother Health Underlying

Food Security and child Services, Hygiene, Causes
gender Sanitation

Human, Economic, and

Institutional Resources

Political and Ideological Structure Basic

Ecological Conditions Causes

Potential Resources

Adapted from UNICEF

Nutrition is Critical in Achieving MDGs
#1. Poverty alleviationan
indicator is % children
underweight
#2. Primary educationbenefits
can accrue when nutrition and
cognition are adequate
#3. Gender equalitybetter
nourished girls likely to stay in
school longer
#4. Child mortalityassociated
with malnutrition
#5. Maternal healthanemia,
iodine deficiency, low BMI
associated with MCH
indicators
#6. Infectious diseases and HIV
AIDSmalnutrition worsens
and makes them more
susceptible to adverse
outcomes
Scaling Up Nutrition (SUN)Main
Elements
Country ownership of nutrition strategies
Scale up of evidence-based interventions, with highest
priority on the first 1,000 days (pregnancy through 24
months)
Multi-sectoral approach; integrating nutrition in related
sectors/using indicators of undernutrition as measures of
progress in related sectors
Scaled up domestic and internal assistance
Interventions and Strategies
 Interventions Proven to Reduce Malnutrition When
Linked with Health Services (Essential Nutrition Actions)
Breastfeeding Complementary feeding Mothers nutrition

Vitamin A and iron Sick/severe cases Iodized salt

 Monitoring and Evaluation
Frameworks for Nutrition Programs
 SO: Vulnerable families achieve sustainable improvement in the
nutrition and health status of seven million women and children by 2006

IR1 Service providers improve quality IR2 Communities sustain activities for
& coverage of maternal and child improved maternal and child survival and
health & nutrition services & key nutrition
systems

IR2.1 Increase awareness of

IR1.1 Coordinate/converge
households & other key audiences
services provided by the Dept. of
about desirable nutrition and
social services (ICDS) and MOH,
health behaviors through multiple
e.g. through Nutrition and Health
channels, e.g. change agents
Days, and block planning
IR2.2 Increase ownership and
participation of community leaders
IR1.2 Build capacity of service and groups in monitoring health
providers, supervisors and and nutrition services and
managers in the dept. of social behaviors
services (ICDS) and MOH

IR2.3 Stronger links between

health systems and communities
Results Framework

Source: Adapted from CARE/India INHP II,

DAP II 2001-2006
Logical Framework
PURPOSE PERFORMANCE MEANS OF ASSUMPTIONS
INDICATORS VERIFICATION
Sustainable 1.Proportion of children 6-35 1.Annual reports - Stable political situation,
improvement months who are from MCH sustained political
in the nutrition malnourished services, commitment and financing
and health 2. Coverage of essential special surveys - Sufficient numbers of
status of nutrition actions: competent health care
women and exclusive BF, 2.Annual reports, personnel and supplies in the
children appropriate CF, vitamin special surveys government sector
through A, iron supplements - No natural disaster or
improved /fortified foods, iodized 3.National / local
tracking reports disease epidemic
services salt use, coverage of
provision and sick and malnourished (surveillance)
community in special programs of high risk
participation areas/
3. Proportion of households populations
at risk of or vulnerable
to food insecurity

NOTE: A logic model would allow a program to select indicators that monitor all stages (inputs, process, outputs)
of their activities e.g. funds and staff available (inputs), training sessions completed (process), number of skilled
workers or villages with trained volunteers (outputs).
Common Indicators
and Data Sources
Categories of Nutrition Indicators

Nutritional status (macro- and micronutrient)

Breastfeeding practices
Complementary feeding practices
Micronutrient supplements/fortified foods
Improved water & sanitation infrastructure and hand
washing behaviors
Individual food consumption, household food security;
vulnerability to food and nutrition insecurity
Most Common Indicators
Nutritional status
Prevalence of stunting (low height-for-age)
Prevalence of wasting (low weight-for-height)
Prevalence of underweight (low weight-for-age) in
children;
Body Mass Index in adults
Anemia prevalence
Prevalence of vitamin A deficiency
Most Common Indicators

Infant and young child feeding practices

Timely initiation of breastfeeding (within 1 hr)
Exclusive breastfeeding rate
Introduction of solid, semi-solid or soft foods
Continued breastfeeding at 1 years
Continued breastfeeding at 2 years
Extra feeding for malnourished/recently sick children
Most Common Indicators
Micronutrient Interventions
Vitamin A supplementation
Iron supplementation
Coverage with iodized salt, other fortified foods
Zinc supplementation for tx of diarrhea
Household Food Security/Vulnerability
Daily meal frequency of family/individuals
Dietary diversity or dietary adequacy
Perceived adequacy of food reserves in the
home/community
Data Collection Systems
Routine
Sentinel food and nutrition surveillance
Institutional health records- clinics, schools, GMP
Feeding & cash or food transfer programs records-
daily/weekly/monthly attendance
Non-Routine
Population-based surveys
Special surveys
Emergency appraisals, rapid assessments
Experimental and operational research
Anthropometric Measures (1)
Children:
Weight-for-age (underweight)
Reflects chronic or acute malnutrition or both
Height-for-age (stunting)
Reflect chronic (prolonged, cumulative) malnutrition
Weight-for-height (wasting)
Reflects acute and recent malnutrition
Anthropometric Measurements (2)

Adults:
Body Mass Index (BMI)
Low weight-for-height ( kg/m2) reflects chronic &/or acute
Mid-upper arm circumference (MUAC)
Thin reflects chronic &/or acute
Data Sources for Anthropometry
MCH programs/clinic records
School feeding- school heights.
Food and nutrition, epidemiological surveillance
Poverty mapping/school height census - heights for chronic,
weights for current
Reports from emergency/refugee programs
Household surveys
Detecting Low Weight-for-Age
Option A Option B

Growth chart Table of weight-for-age cut-off

points

Cut-Off Points
Low Weight-for-Age

Girls Boys
Age Age
mths mths

Low wt/age
Low wt for age
below this line
below this line
Statistical Presentation of Anthropometric
Indicators
Prevalence
Percent below a cut-off, such as <-2SD or < -3 SD
Mean Z-score values (in SD units)
Z score refers to how far and in what direction the measure
deviates from the median of the NCHS/WHO international
reference standard
Exercise: Interpreting Standard DHS
Nutrition Status Tables

If 50% of children are stunted (e.g. height-for-age Z-

scores less than -2) what does this indicate?
What if, in the same population, 30% are underweight
and 15% are wasted?
Which child is more vulnerable to die: a -3sd wasted or a
-3sd stunted child? Why? In which age group?
By which characteristics would you recommend
disaggregating these data?
Feeding Practices

Percentage of infants less than 24 months of age who were

put to the breast within one hour of delivery
Percentage of infants aged 0-5 months who were fed
exclusively with breast milk in the last 24 hours
Percentage of infants aged 6-8 months who received solid or
semi-solid food the previous day
Feeding Practices
Percentage of infants and young children 6 to 23 months of
age who receive a minimum acceptable diet:
6 to 8 months of age : Breastmilk + other food at least
2 times per day + 4 or more food groups
9 to 23 months of age : Breastmilk + other food at
least 3 times per day + 4 or more food groups
For non-breastfed infants 6 to 23 months of age : 2
milk feedings + diversity and frequency of meals as
above by age group
Coverage Indicators for Micronutrient
Programs
Percent of children aged 6-59 months who received a high
dose vitamin A supplement in the last 6 months
Percent of households consuming adequately iodized (i.e. 15+
ppm of iodine) salt
Percent of pregnant women who received the recommended
number of iron/folate supplements during pregnancy
Choices in Program M&E Design
Which age groups to measure?
Anthropometry, infant and young child feeding
How to obtain valid measurements
Anthropometry; micronutrients; infant and young child
feeding
Timing
Trends; seasonality
Evaluation design
Examples of Flaws in Nutrition Evaluations
No comparison groups
No pretest or baseline
No control for age, e.g. < 6 mo.,< 2 and 3+ yrs
Not accounting for confounding factors
Seasons not comparable
Not controlling for mortality reduction
Non-representative samples, small samples
Pilot projects, not replicable
Economic Analysis in Nutrition M&E
Cost-effectiveness analysis
compares two or more alternatives for achieving coverage or
scale or behavior change, or a process outcome such as
training to build capacity
Answers the question Which is the more efficient option?
Used more in evaluations
Cost-benefit
compares the resources required to achieve impact and the
monetary value of that impact
Answers the question Is the investment worthwhile?
Based on many assumptions with limited empirical evidence
Additional Considerations
Gender:
Intra-household dynamics
Micronutrient requirements/deficiencies differ by sex
Geography:
Ecological zones
Proximity to markets
Example: ENA Indicators
Use of
Data to 100
Assess
90
Program
48
80
Gaps 53
70
54
65 59 58
60
Unmet
50 need

40 Current
coverage
30
47 52
46 41 42
20 35
10

0
EBF in children Weight/age - Vit A supp. for Pregnant Amount of food Iodized salt
<5 months 2SD in children children 6-59 women who is maintained consuption
0-35 months months (one received iron or increased (>15ppm)
dose) tablets during dirrahea
M&E Challenges
Challenges of M&E
Multisectoral programs (attributing outcome?)
Clinical Indicators
May need large samples (e.g., xerophthalmia, feeding
practices for 6-8 month old infants)
May be sensitive to enumerator training (e.g., goiter)
Measurement of iron deficiency (lack of specificity)
Selection bias (institution-based sample)
Challenges: Comparisons & Trends
Sample design
Sample size
Cutoff points & standards
Seasonality
References
Arimond, Mary and Marie T. Ruel. 2003. Generating Indicators of
Appropriate Feeding of Children 6 through 23 Months from the KPC 2000+.
Washington, D.C.: Food and Nutrition Technical Assistance Project,
Academy for Educational Development.
Black RE. 2008. Maternal and child undernutrition: global and regional
exposures and health consequences. Lancet, 371: 243-60.
Bhutta ZA et al. 2008. What works? Interventions for maternal and child
undernutrition and survival. Lancet, 371: 417-40.
Cogill, Bruce. 2003. Anthropometric Indicators Measurement Guide.
Washington, D.C.: Food and Nutrition Technical Assistance Project,
Academy for Educational Development.
Wasantwisut, Emorn. 2002. Recommendations for monitoring and
evaluating vitamin A programs: outcome indicators. Journal of Nutrition, 132:
2940S-2942S.
Ruel, M.T., K.H. Brown, and L.E. Caulfield. 2003. Moving Forward with
Complementary Feeding: Indicators and Research Priorities. Food
Consumption and Nutrition Division Discussion Paper #146. Washington,
D.C.: International Food Policy Research Institute.
References
Victora CG et al. 2008. Maternal anc child undernutrition: consequences for
adult health and human capital. Lancet, 371: 340-57.
WHO. 2001a. Assessment of Iodine Deficiency Disorders and Monitoring
their Elimination: A Guide for Programme Managers. Second Edition.
WHO/NHD/01.1. Geneva: World Health Organization.
WHO Multicentre Growth Reference Study Group. WHO Child Growth
Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-
for-height and body mass index-for-age: Methods and development.
Geneva: World Health Organization, 2006
WHO. 2001b. Iron Deficiency Anaemia: Assessment, Prevention and
Control - A Guide for Programme Managers. WHO/NHD/01.3. Geneva:
World Health Organization.
WHO. Indicators for assessing infant and young child feeding practices part
1: definitions. Geneva, World Health Organization, 2008.
Madagascar Nutrition Case Study
During 19962002, Madagascar followed a comprehensive
model, the essential nutrition actions (ENA) framework, which
coordinated efforts from the community level through national
policy making, and included both government and non-
government entities. The model was first implemented in two
districts in the Antananarivo and Fianarantsoa provinces. It
focused on a set of proven interventions covering micronutrients
and dietary practices for mother and young children. From 1995
to 1998, the overall focus was placed on designing mechanisms
that linked nutrition interventions more directly with other child
health and RH services, and national- and community-level
actions. Further instructions are provided in the handout.
MEASURE Evaluation is funded by the U.S. Agency for
International Development (USAID) and implemented by the
Carolina Population Center at the University of North Carolina at
Chapel Hill in partnership with Futures Group, ICF Macro, John
Snow, Inc., Management Sciences for Health, and Tulane
University. Views expressed in this presentation do not necessarily
reflect the views of USAID or the U.S. government. MEASURE
Evaluation is the USAID Global Health Bureau's primary vehicle for
supporting improvements in monitoring and evaluation in
population, health and nutrition worldwide.