Monitoring and Evaluation:
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
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The problem of malnutrition
Interventions and strategies
M&E frameworks for nutrition programs
Common indicators & data sources
M&E challenges
The Problem
• Malnutrition contributes to over half of all child
deaths, (60%)
• Malnutrition is largely hidden, (mild, moderate, ?)
Importance of malnutrition as an underlying factor
in under-five mortality in Ethiopian Children.
Others
Perinatal
Complications
Diarrheal
Diseases
Malnutritio
n
58%
Malaria
Measles
Acute
Respiratory
Infections
WHO ’98
Micronutrient deficiencies
Micronutrient deficiencies have severe
consequences;
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Iodine deficiency damages intellectual
development,
• 50% of pregnant women and 40-50% of
children < 5 in developing countries are iron
deficient,
• VAD affects > 100 million children, and is
responsible for as many as one out of every
four child deaths in places with Vitamin A
deficiency,
•How
maternal
and child
nutrition
are linked
Causes of Malnutrition:
conceptual framework
Nutrition and Development
• Nutritional status is a key indicator of progress in attaining
MDGs;
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Eradicate extreme poverty and hunger (Goal 1),
Achieve universal primary education (Goal 2),
Promote gender equality and empower women (Goal 3),
Reduce child mortality (Goal 4),
Improve maternal health (Goal 5),
Combat HIV/AIDS, malaria and other diseases (Goal 6),
Ensure environmental sustainability (Goal 7),
Develop a global partnership for development (Goal 8)
Nutrition is Critical in Achieving MDGs
#1. Poverty alleviation - an
indicator is % children
underweight
#2. Primary education benefits can accrue when
nutrition and cognition are
adequate
#3. Gender equality- better
nourished girls likely to
stay in school longer
#4. Child mortality - 60%
associated with
malnutrition
#5. Maternal health anemia, iodine deficiency,
low BMI associated with
health indicators
#6. Infectious diseases and
HIV AIDS- malnutrition
worsens and makes them
more susceptible to
adverse outcomes
World Fit for Children Goals
• Reduction of child malnutrition among children under five
years of age by at least one third, with special attention to
children under two years of age.
• Achieve the sustainable elimination of iodine deficiency
disorders by 2005
• Achieve the sustainable elimination of vitamin A deficiency
by 2010
• Reduce the prevalence of anemia (including iron
deficiency) by one third by 2010
Interventions and
Strategies
Interventions Proven to Reduce Malnutrition
When Linked with Health Services
(Essential Nutrition Actions)
Mother’s
Complementary
Breastfeeding
feeding
nutrition
Vitamin A
and iron
Sick/severe
cases
Iodized salt
Monitoring and Evaluation
Frameworks
for
Nutrition Programs
Results Framework
SO: Vulnerable families achieve sustainable improvement in the
nutrition and health status of seven million women and children by 2008
IR1 Service providers improve quality
& coverage of maternal and child
health & nutrition services & key
systems
IR1.1 Coordinate/converge
services provided by the Dept. of
social services (ICDS) and MOH,
e.g. through Nutrition and Health
Days, and Block planning
IR1.2 Build capacity of service
providers, supervisors and
managers in the dept. of social
services (ICDS) and MOH
Source: Adapted from
CARE/India INHP II,
DAP II 2001-2006
IR2 Communities sustain activities for
improved maternal and child survival and
nutrition
IR2.1 Increase awareness of
households & other key audiences
about desirable nutrition and
health behaviors through multiple
channels, e.g. ‘change agents’
IR2.2 Increase ownership and
participation of community leaders
and groups in monitoring health
and nutrition services and
behaviors
IR2.3 Stronger links between
health systems and communities
Logical Framework
PURPOSE
Sustainable
improvement
in the nutrition
and health
status of
women and
children
through
improved
services
provision and
community
participation
PERFORMANCE
INDICATORS
1.Proportion of children 6-35
months who are
malnourished
2. Coverage of essential
nutrition actions:
exclusive BF,
appropriate CF, vitamin
A, iron supplements
/fortified foods, iodized
salt use, coverage of
sick and malnourished
in special programs
3. Proportion of households
at risk of or vulnerable
to food insecurity
MEANS OF
VERIFICATION
1.Annual reports
from MCH
services,
special surveys
2.Annual reports,
special surveys
3.National / local
tracking reports
(surveillance)
of high risk
areas/
populations
ASSUMPTIONS
- Stable political situation,
sustained political
commitment and financing
- Sufficient numbers of
competent health care
personnel and supplies in the
government sector
- No natural disaster or
disease epidemic
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
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Nutritional status
Breastfeeding practices
Complementary feeding practices
Micronutrient supplements/fortified foods
Household food security; vulnerability to
food and nutrition insecurity
Most Common Indicators
• Nutritional status
– Weight-for-age and/or height-for-age
– Body Mass Index in women
– Anemia prevalence
– Vitamin A deficiency
• Infant and young child feeding practices
– Timely initiation of breastfeeding
– Exclusive breastfeeding rate
– Complementary feeding rate
– Extra feeding for malnourished/recently sick
children
Most Common Indicators
• Micronutrient Interventions
– Vitamin A supplementation
– Iron supplementation
– Coverage with iodized salt, other fortified foods
• Household Food Security/Vulnerability
– Daily meal frequency of family/individuals
– Perceived inadequacy of food reserves in the
home/community
Data Collection Systems
Routine
• Sentinel food and nutrition surveillance
• Institutional health records- clinics, schools
• Feeding & cash or food transfer programs recordsdaily/weekly/monthly attendance
Non-routine
• Population-based 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
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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
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
Age
mths
Low wt/age
Low wt for age
below this line
below this line
Boys
Age
mths
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 low HFA is 50%, WFA is 30%, WFH is 15%,
which is the worst problem? Why?
• Which child is more vulnerable to die: a -sd
wasted or a -3sd stunted child? Why? In which
age group?
• Which characteristics are more important for
program targeting: rural/urban, region, sex,
age, or birth order?
Feeding Practices:
M&E Considerations
• Proportion of infants aged 0-5 months who were
exclusively breastfed in the last 24 hours,
• Proportion of infants less than 12 months of age
who were put to the breast within one hour of
delivery,
• Proportion of infants aged 6-9 months receiving
breastmilk & complementary foods,
• Mean number of food groups eaten in the last
24 hours by children 6-23 months of age,
Appropriate Complementary
Feeding
• Percentage of infants and young
children 6 -23 months of age who
receive appropriate complementary
feeding
• 6 to 8 months of age : Breastmilk + other food at
least 2-3 times per day + variety of food groups
• 9 to 11 months of age : Breastmilk + other food at
least 3-4 times per day + variety of food groups
• 12 to 23 months of age : Breastmilk + other food
at least 3-4 times per day + variety of food groups
Coverage Indicators for
Micronutrient Programs
• Proportion of children aged 6-59 months who
received a high dose of vitamin A in the last 6
months,
• Proportion of households consuming adequately
iodized (i.e. 15+ ppm of iodine) salt,
• Proportion 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
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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
Example: Use of Data to Assess
Program Gaps
ENA Indicators
100
90
80
70
54
65
59
58
53
48
60
Unmet
need
50
Current
coverage
40
30
20
46
35
41
42
47
52
10
0
EBF in children Weight/age Vit A supp. for
<5 months
2SD in children children 6-59
0-35 months
months (one
dose)
Pregnant
women who
received iron
tablets
Amount of food
is maintained
or increased
during dirrahea
Iodized salt
consuption
(>15ppm)
Monitoring and
Evaluation
Challenges
Challenges of M&E
• Multisectoral programs (attributing outcome?)
• Clinical Indicators
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May need large samples (e.g. xerophthalmia)
May be sensitive to enumerator training (e.g. goiter)
Measurement of iron deficiency (lack of specificity)
Selection bias (institution based sample)
Challenges: Comparisons & Trends
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Sample design
Sample size
Cutoff points & standards
Seasonality
References
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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.
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.
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. 2001b. Iron Deficiency Anaemia: Assessment, Prevention and
Control - A Guide for Programme Managers. WHO/NHD/01.3. Geneva:
World Health Organization.
Wellstart International’s Tool Kit for Monitoring and Evaluating Breastfeeding
Practices and Programs.
Madagascar Nutrition Case Study
During 1996-2002, 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 nationaland community-level actions. Further instructions are provided
in the handout.