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 middleincome 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
Conceptual
Framework—
Causes of
Malnutrition
Long term consequences:
adult size, intellectual ability, economic
productivity, reproductive performance,
metabolic, cardiovascular disease
Short-term
consequences:
Mortality, morbidity
Nutritional Status
Feeding practices
Household
Food Security
Care of mother
and child…
gender
Health
Immediate
Causes
Health
Services, Hygiene,
Sanitation
Underlying
Causes
Human, Economic, and
Institutional Resources
Political and Ideological Structure
Ecological Conditions
Potential Resources
Adapted from UNICEF
Basic
Causes
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—associated
with malnutrition
#5. Maternal health—anemia,
iodine deficiency, low BMI
associated with MCH
indicators
#6. Infectious diseases and HIV
AIDS—malnutrition 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
Vitamin A and iron
Complementary feeding
Sick/severe cases
Mother’s nutrition
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
& 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
Results Framework
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
 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 recordsdaily/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
Low wt/age
Low wt for age
below this line
below this line
Girls
Boys
Age
mths
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 50% of children are stunted (e.g. height-for-age Zscores 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:
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
Vit A supp. for
EBF in children Weight/age 2SD in children children 6-59
<5 months
months (one
0-35 months
dose)
Pregnant
women who
received iron
tablets
Amount of food
is maintained
or increased
during dirrahea
Iodized salt
consuption
(>15ppm)
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


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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.
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

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

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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, weightfor-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 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 nongovernment 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.