Undernutrition contributes to nearly 45 percent of deaths in infants below 5 years of age (Black et al., 2013). Globally, nearly one in four children or 151 million infants below 5 years were stunted in 2017 and 51 million suffered from wasting (UNICEF / WHO / World Bank Group Joint Child Malnutrition Estimates, 2018).
Studies have shown that first 1,000 days of a child are most critical as infants and young children are exceptionally vulnerable to poor diet and infection during this time. There is a need for strong advocacy for empowering women through programmes, which can improve maternal, infant, and young child nutrition (MIYCN). Integration of family planning (FP) services (to avoid unintended pregnancy and choose whether or when to have a child) and MIYCN programmes have a crucial role to play.
Integration of family planning and reproductive health services in nutrition programming, an important intervention, is often overlooked. To date there has been limited documentation on integrating family planning with nutrition programmes in India. Therefore, in an effort to fill the evidence gap in this area, the Coalition for Food and Nutrition Security with the support of CTARA, IIT Bombay, conducted a preliminary review including evaluation of programmes that have integrated family planning and nutrition, success stories thereof and plausible strategies to link the two.
The study, funded by Population Foundation of India, was divided into two broad components: a) Literature Review and b) Secondary Data Analysis. Through literature review, we captured studies that show influence of family planning on maternal and child nutrition outcomes around the world, programmes that integrated FP and nutrition, their challenges and success stories. Whereas, secondary data analysis was carried out to study current status of nutrition and family planning indicators in India, effect of family planning indicators on nutritional outcomes and regional variation in India. For conducting secondary analysis, data from recent National Family Health Survey – 4 (NFHS 4) conducted in 2015-16 was used.
Many Programmes have integrated Family Planning and Nutrition in India such as Pragati Child Survival Project, World Vision (2003-07), which is an example of timed and targeted approach through the lifecycle or continuum of care approach where key messages were bundled, timed, and targeted to reach families through a series of seven scheduled visits by community health workers. Of these, three were during pregnancy, one after childbirth, and three during infancy. Social Marketing Strategies for Maternal and Child Health Project by Population Services International (2002–05) developed a network of trained private health providers, retailers, and female community health volunteers to provide information and promote PSI’s products related to four maternal and child health issues—maternal and newborn care, diarrheal diseases, birth spacing, and child nutrition.
Reproductive and Child Health, Nutrition and HIV/AIDS Program (RACHNA) by CARE (2001–06) supported implementation of India’s Integrated Child Development Services and Reproductive and Child Health Programmes. Integrated services were delivered by Anganwadi (childcare) workers at various contact points including through home visits, at Anganwadi centres, besides health and nutrition days. Family planning/child spacing education, counseling, and referrals were integrated into the integrated nutrition and health programme interventions, which included food supplementation, vitamin A, iron and folic acid, improved breastfeeding, and complementary feeding.
Apart from above three, Bihar’s family planning programme in 2010-12 focused on stabilizing population growth mainly through female sterilization. Cash incentives were offered to women, community workers, and service providers to increase the demand for and availability of tubal ligations. Women under 30 years of age received Rs 10,000 if they underwent a tubal ligation after the second child.
Although the Primary Healthcare System distributes free condoms, IUDs, and birth control pills, the delivery of programmes to prevent teenage pregnancies and encourage birth spacing has typically fallen to NGOs such as Janani and Pathfinder. However, there was a change with increased recognition of the consequences of early and frequent pregnancies for maternal and child health.
In 2011, the National Rural Health Mission launched the Healthy Timing and Spacing of Pregnancies Initiative in three districts of Bihar using the behaviour change communication model developed by Pathfinder’s PRACHAR programme. Although NGOs have had some success with birth spacing, they have found it much more difficult to persuade couples to delay the birth of their first child until the mother was 18 due to strong social pressure on newly married couples to demonstrate fertility by producing a child, especially a son.
In the short run, laws that prohibit child marriage and schemes encouraging girls to stay in school and wait until age 18 to marry could be more effective than family planning programmes in preventing teenage pregnancies. Since passing the Prevention of Child Marriage Act in 2006, Bihar has been providing cash incentives to girls and their families to delay marriage until they have turned 18. Through the Mukhyamantri Balika Cycle Yojana, the Bihar government has been providing free bicycles, school uniforms and books to ensure adolescent girls continue with their education. It is likely that this scheme, together with better roads and security, has contributed to a large decline in the percentage of out-of-school girls aged between 11 to 14 years in rural Bihar, which dropped from 17.6% in 2006 to 4.6% in 2010.
Family planning affects people in myriad ways. Most fundamentally, it advances human rights. Knowledge and use of family planning methods can regulate planning of birth in terms of birth interval and nutritional status of mothers and children, birth order and nutritional status of children.
Short pregnancy intervals are associated with increased risk of infants being born preterm, small-for-gestational age, and with low birth weight, all of which are key indicators of childhood undernutrition, including wasting, stunting, underweight, and anaemia. Spacing births too closely can also affect nutrition outcomes of all children in the family when the mother’s ability to breastfeed them properly is compromised along with lack of time and resources to provide adequate nutritious food and care for all children. Adolescent pregnancy can result in adverse nutritional outcomes for both the mother and the foetus, with increased risk of adverse perinatal outcomes such as preterm birth, low birth weight, and small-for-gestational age.
Regional variations in family planning indicators can be observed at state level, and similar study at district and block levels can present a sharper and clearer picture, which can be useful for developing strategic action for reducing undernutrition.