Women's Nutrition

 

Women’s nutritional health is vitally important in relation to women’s quality of life and their reproductive health and pregnancy outcomes.  Women’s nutrition is directly linked to three of the UN Millennium Development Goals: #1. end poverty and hunger; #4. reduce child mortality; and #5. improve maternal health. Links with other goals may be less direct, but are still salient including: #3. achieve gender equality and empower women (for access to food and related resources); #6. combat HIV/AIDS, malaria, and other diseases (which affect and are affected by nutritional status); and #7. ensure environmental and agricultural sustainability (which impacts women’s roles in food production and their access to food and environmental resources). In its first principle supporting long-term systematic changes in global health by implementing women- and girl-centered approaches, the Global Health Initiative (GHI) seeks to remove barriers and increase access to quality health services (GHI, 2010).  Increasing access to food resources and nutrition care, particularly in settings where women and girls often eat ‘last and least,’ is an essential component of programs addressing their health and is consistent with GHI strategies. Nutrition deficiencies and related conditions, including underweight, height stunting, anemia, vitamin A deficiencies and night blindness, low birth weight, and micronutrient-related birth defects, such as neural tube defects resulting from folic acid deficiency, continue to be major concerns for women’s health and reproductive outcomes in developing countries.  Serious problems with women’s undernutrition (BMI 18.5 kg/m2) are evident in many regions and markedly so among countries in sub-Saharan Africa and south-central and southeastern Asia (Black et al., 2008). In addition to the high prevalence of undernutrition among women and girls in many regions and countries, there are growing issues surrounding overweight and obesity. Current evidence has clearly demonstrated that overweight and obesity and related non-communicable diseases have been exploding in low- and middle- income countries (Global Burden of Disease Report, 2012).  The emerging challenges associated with the “Double Burden” of over and under nutrition occurring side by side across populations, low income groups and even within the same households may be associated with both quality and quantity of the diet as well as metabolic consequences of overweight/obesity. Survey evidence for over two decades from developing countries has been demonstrating steady and widespread increases in the prevalence of overweight and obesity among adults, as well as, children and adolescents. In response to the recommendations of WHO’s Expert Consultation on Obesity, an online WHO Global Database on Body Mass Index (BMI) was created to monitor country-level and regional over- and under-nutrition trends.     Weight gain during pregnancy is one of the most critical factors in determining both birth outcomes and maternal nutritional outcomes of pregnancy. Weight gain is particularly important for women who are underweight prior to pregnancy, however, given the rising numbers of overweight and obese women of reproductive age, recommended weight gains for normal to overweight women and concerns with excess weight gain need to be taken into consideration. Pre-pregnancy obesity and excess weight gain during pregnancy are risk factors for heavier babies (Li et al., 2013).  In addition, a study has shown that high pregnancy BMI substantially increases the risk of postpartum anemia (Bodnar et al, 2012). Thus, more emphasis should be put on this population as well. In 2009, the Institute of Medicine (IOM) set guidelines for recommended weight gain ranges based on four levels of women’s pre-pregnancy body mass index (BMI) (IOM, 2009). Intervention programs for undernutrition target three main problems: (1) general nutritional deficiency (e.g., inadequate dietary intake), (2) specific micronutrient deficiencies, and/or (3) diseases directly affecting nutritional outcome (e.g., malaria, helminthes, and HIV/AIDS). Strategies addressing the first two problems include provision of supplements (food supplements, micronutrients), food production strategies, food-based strategies (genetic engineering, agricultural interventions), and dietary behavior change.  Interventions to combat malaria, parasitic diseases, and HIV/AIDS include preventive and therapeutic treatment.  UNICEF considers nutrition interventions for women and children among the most affordable and cost-effective development investments countries can make (UNICEF, 2009). For a review of the scope and effectiveness of a range of international interventions targeting maternal and child nutrition, see Bhutta, et al., 2008). The increasing programmatic emphasis on women’s nutrition requires needs assessments and effective monitoring and evaluation, ideally with core indicators consistent with DHS and country surveillance sources (Cogill, 2003; CORE Group et al., 2010). The thirteen indicators selected for this database cover the recommended ranges for pregnancy weight gain, anthropometric measures of nutritional status including underweight, overweight and obesity, key micronutrient deficiencies (iron/folate, iodine and Vitamin A), and supplies of vitamin and mineral supplements.  For indicators on diseases affecting nutritional outcomes, such as malaria and helminths, see the database technical areas for Malaria in Pregnancy and Safe Motherhood, respectively.  Because the interactions of nutritional status with HIV/AIDS are of special significance to women’s health and their infants’ welfare, the database also includes Women’s Nutrition and HIV as a separate technical area.  Additional online sources for nutrition indicators and surveillance data are the WHO Nutrition Landscape Information System (NLIS) and the WHO Vitamin and Mineral Information System (VMNIS). ___________  References: ACC/SCN and IFPRI, 2000, The 4th World Nutrition Situation Report: Nutrition through the Life Cycle, Geneva, UN. Bhutta, ZA, Ahmed T, Black, RE, Cousens S, Dewey K, Guigliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS, Shekar M, ‘What Works? Interventions for maternal and child undernutrition and survivial,’ Lancet 2008; 371:41-64. Black, RE, Allen, LH, Bhutta, ZA, Caufield LE, de Onis, M, Ezzati, M, Mathers, C, Rivera, J,, ‘Maternal and child undernutrition: global and regional exposures and health consequences,’ Lancet 2008; 371: 243-260. Cogill B, 2003, Anthropometric Indicators Measurement Guide,  FANTA-2, Washington, DC: USAID. CORE Group, FANTA-2, Save the Children and USAID, 2010, Nutrition Program Design Assistant: A Tool for Program Planners (NPDA), Reference Guide, Washington DC.: USAID. Institute of Medicine and National Research Council, 2009, Weight Gain during Pregnancy: Reexamining the Guidelines, Eds: Kathleen Rasmussen and Ann Yaktine, Washington, D.C.: The National Academy Press. UNICEF, 2009, Tracking Progress on Child and Maternal Nutrition, New York. http://www.unicef.org/publications/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_EN_110309.pdf WHO, Global Database on Body Mass Index , http://apps.who.int/bmi/index.jsp WHO, 2010, Nutrition Landscape Information System (NLIS), Country Profile Indicators Interpretation Guide, Geneva: WHO. http://whqlibdoc.who.int/publications/2010/9789241599955_eng.pdf WHO, Vitamin and Mineral Information System (VMNIS), Department for Health and Development (NHD), Geneva, Switzerland. Online database at http://www.who.int.vmnis/en/       Li, S., Rosenberg, L., Palmer, J. R., Phillips, G. S., Heffner, L. J. and Wise, L. A. (2013), Central adiposity and other anthropometric factors in relation to risk of macrosomia in an african american population. Obesity, 21: 178–184. doi: 10.1002/oby.20238   Lisa M. Bodnar, Anna Maria Siega-Riz and Mary E. Cogswell (2012), High Prepregnancy BMI Increases the Risk of Postpartum Anemia. Obesity, 6: 941-948. DOI: 10.1038/oby.2004.115  

Percent of women who gain weight in the last two trimesters of pregnancy within the recommended range for their weight status

Definition:

The percent of women who gain within the recommended kg/month range during the second and third trimesters of pregnancy for their weight status (underweight, normal weight, overweight or obese) based on pre-pregnancy or very early pregnancy body mass index (BMI) levels.  Recommended ranges for gestational weight gain (GWG) are based on the Institute of Medicine guidelines (IOM, 2009).

This indicator is calculated as:

(Number of women by weight category gaining in recommended kg/month range in second and third trimesters of pregnancy / Total number of pregnant women in weight category) x 100

The GWG ranges by pre-pregnancy BMI status are as follows:

                                                Recommended GWG Ranges in Kg

Weight Status                 Weekly                   Monthly*              Total GWG

Underweight                   0.44 - 0.58             1.9 - 2.5              12.5 - 18.0

(BMI <18.5)

Normal Weight               0.35 - 0.50            1.5 - 2.1               11.5 – 16.0

(BMI 18.5 - <25)          

Overweight                     0.23 – 0.33            1.0 - 1.4                7.0 – 11.5

(BMI 25 - <30)

Obese                              0.17 – 0.27           .75 -1.2                  5.0 – 9.0 

(BMI 30+)

* The recommended monthly GWG ranges for the 2nd and 3rd trimesters were calculated by multiplying the weekly ranges by 4.3.

From: Weight Gain During Pregnancy: Reexamining the Guidelines  (IOM, 2009). The table is available online at http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx.  Also see Tumilowicz (2010) for use of the IOM tables for GWG recommendations for women with HIV based on the IOM guidelines.

BMI is calculated as:  Weight in kg / (Height in m)2

There are numerous tools (charts, websites, and computer applications) available to calculate BMI.

Data Requirements:

Measurement of BMI (height and weight) pre-pregnancy or early in first trimester of pregnancy and two or more recordings of weight after the third month of pregnancy. The repeated measures of weight during pregnancy may not be taken at even monthly intervals and will require interpolation based on the number of weeks or months between measurements in order to calculate and categorize by the recommended ranges.

Data Sources:

Service statistics, antenatal care (ANC) cards, or other clinic-based records; samples of home or community-based records reviewed

Purpose:

This indicator measures weight gain during pregnancy, one of the most critical factors in determining both birth outcomes and maternal nutritional outcomes of pregnancy. Weight gain is particularly important for women who are underweight prior to pregnancy and for women who are pregnant during times of acute nutritional stress, such as famines or seasons of food scarcity.  Conversely, the prevalence of overweight has been increasing worldwide during the past two decades resulting in a “double burden” of health concerns stemming from the co-existence of under- and over-nutrition in many regions.  Given the rising numbers of overweight and obese women of reproductive age, recommended GWG for normal to overweight women and concerns with excess GWG need to be taken into consideration.  This indicator relates to three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health. 

The 2009 IOM guidelines are based on observational studies which show that women who gain within the recommended range for their weight status had better pregnancy outcomes than those who did not.  Ranges are used for each of the weight categories given the imprecision of the estimates used to develop the guidelines, and they are intended to be used with good clinical judgment at the individual client level. Based on a systematic review of studies, strong associations were found between GWG below the IOM guidelines with preterm birth, decreased birthweight, fetal growth small for gestational age, and failure to initiate breastfeeding (Viswanathan et al., 2008; Siega-Riz et al., 2009) .

Weight gains above the IOM recommendations were associated with increased birthweight and fetal growth large for gestational age (LGA), as well as, postpartum weight retention (Siega-Riz et al., 2009).  In a prospective cohort study, Crane et al. (2009) found that for women with normal pre-pregnancy BMI, excess GWG was associated with increased rates of gestational hypertension, augmentation of labor, and LGA birthweight.  For overweight women, excess GWG was associated with increased rates of gestational hypertension and LGA birthweight, and for women who were obese or morbidly obese, excess GWG was associated with increased rates of LGA birthweight and neonatal metabolic abnormality. 

This indicator reflects the importance of routine and high-quality ANC through multiple prenatal visits. Moreover, it focuses the attention and care of both the health worker and the woman on weight gain and healthy weight gain promotion rather than simply on determining maternal nutritional status at any one point in time.

Issue(s):

The recommended ranges from the IOM guidelines were designed for use with American women and may be applicable for use with women in other developed countries.  They are not intended for use in areas where women are substantially shorter or thinner or where adequate obstetric services are unavailable.  There have not been recommended ranges by weight status set for developing country settings and the higher end of the IOM ranges may overestimate weight gain for women of short stature, particularly for women with severe stunting (<145 cm).  An earlier version of the indicator  ‘Percent of women who gain at least one kg per month in the last two trimesters of pregnancy’  did not differentiate by women’s weight status and set the threshold very low for underweight to normal weight women.  A WHO report (1995) indicated that a higher gain of 1.5-2.0 kg per month decreased LBW and intrauterine growth retardation.   

The indicator requires not only an estimate of pre-pregnancy BMI, but additional calculations to interpolate the recommended GWG range for the interval between pregnancy weight measurements.  These calculations can be more complicated if the intervals vary and are not evenly spaced by month.

Another limitation with this indicator is that the population covered may not fully represent the intended population, because a very small percentage of women in many developing countries routinely attend ANC services. Frequent attendees tend to be either women with pregnancy complications or women of higher socio-economic and educational status. The difficulty in monitoring maternal nutrition during pregnancy is that many women do not get ANC, or they have only one visit late in the pregnancy.

A GWG indicator is most often used by organizations working in a limited geographic area. Evaluators face difficulty obtaining this information from large public health centers in developing countries that keep ANC records.

Gender Implications:

Limiting food intake during pregnancy even for under and normal weight women is a gender-based, harmful cultural practice theoretically linked to the idea that limiting weight gain will reduce the infant’s head circumference, so that the birth will be less difficult.  More efforts are needed to educate husbands, mothers-in-law, and communities that particularly underweight and normal weight pregnant women must eat more, not less, and that nutritious foods benefit both mother and fetus and lead to better birth outcomes.

References:

Crane JM, White J, Murphy P, Burrage L, Hutchens D., The effect of gestational weight gain by body mass index on maternal and neonatal outcomes. J Obstet Gynaecol Can. 2009 Jan;31(1):28-35.

Institute of Medicine and National Research Council, 2009, Weight Gain during Pregnancy: Reexamining the Guidelines, Eds: Kathleen Rasmussen and Ann Yaktine, Washington, D.C.: The National Academy Press. http://www.ncbi.nlm.nih.gov/pubmed/20669500   

Siega-Riz AM, Viswanathan M, Moos MK, Deierlein A, Mumford S, Knaack J, Thieda P, Lux LJ, Lohr KN. A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: birthweight, fetal growth, and postpartum weight retention. Am J Obstet Gynecol. 2009 Oct;201(4):339.e1-14.

Viswanathan M, Siega-Riz AM, Moos MK, Deierlein A, Mumford S, Knaack J, Thieda P, Lux LJ, Lohr KN., Outcomes of maternal weight gain. Evid Rep Technol Assess (Full Rep). 2008 May;(168):1-223.

Tumilowicz A, 2010, Guide to Screening for food and Nutrition Services among adolescents and adults living with HIV, Washiggton, DC: FANTA/AED.

WHO, 2010, A Review of Nutrition Policies: Draft Report, Geneva: WHO.

WHO Global Database on Body Mass Index , http://apps.who.int/bmi/index.jsp

WHO, 1995, Maternal Anthropometry and Pregnancy Outcomes: A WHO Collaborative Study, Geneva: WHO.

Percent of non-pregnant women of reproductive age who have a low body mass index (BMI <18.5)

Definition:

The percent of non-pregnant women ages 15 to 49 who have a body mass index (BMI) that is less than 18.5 kg/m2.  BMI is the ratio of weight to height squared (kg/m2) and a low BMI measures thinness and possible chronic energy deficiency in non-pregnant women.

 

This indicator is calculated as:

(Number of non-pregnant women ages 15 to 49 with a BMI <18.5 / Total number of non-pregnant women between the ages of 15-49)  x 100

BMI is calculated as:  Weight in kilograms / (Height in meters)2

There are numerous tools (charts, websites, and computer applications) available to calculate BMI.

The standard cut-off for underweight in non-pregnant, non-lactating women aged 15-49, determined by WHO (2004) and used by the Institute of Medicine (IOM, 2009) is a BMI of <18.5.  Further cutoffs for categories of underweight are listed below:

For the full BMI reference table, see WHO Global Database for BMI (2010)

Data Requirements:

Measurement of weights and heights of non-pregnant women of reproductive age.  Data may be disaggregated by age grouping, levels of underweight based on WHO cutoffs, by lactation status for postpartum women, and, where data are available, by relevant socioeconomic and demographic factors such as education, income, and urban/rural residence.

Data Sources:

 

Population-based surveys; surveillance systems; health facility records

Purpose:

A well-accepted measure of weight status, BMI is a self-contained ratio highly correlated with weight-for-height that does not require reference tables for interpretation.  Although this indicator specifies non-pregnant women, BMI during early pregnancy is commonly used to identify women who need to gain more weight in order to improve infant outcomes of pregnancy including, intrauterine growth retardation (IUGR), low birth weight (LBW), and perinatal mortality.  This indicator relates to three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health.

The consequences of undernutrition for women and for their offspring are serious and often long-term.  Women experiencing moderate to severe thinness also are more likely to have vitamin and mineral deficiencies with accompanying anemia, goiter, possible immune suppression, and reduced well-being and productivity.  In a series of studies and meta-analyses, the Maternal and Child Undernutrition Study Group has estimated that 22 percent of childhood deaths can be attributed to childhood underweight and maternal low BMI functioning through IUGR to affect LBW (Black et al., 2008).  Based on data from prospective studies in five countries, Victoria, et al. (2008) found that the effects of undernutrition can span at least three generations.  There were small but significant associations between grandmother’s heights and their grand children’s birth weight from the five cohorts. 

Stunting of height in adolescent to adult women is associated with undernutrition during their early childhood and has effects on pregnancy outcome independent of BMI.  Severe stunting (height <145 cm) and short stature (146 to 157 cm) increase risk of caesarean delivery largely linked to cephalopelvic disproportion (WHO, 1995).  Low BMI does not appear to increase the risk of pregnancy complications, whereas, short stature and higher BMI together can increase these complications and need for assisted delivery (Cnattingius et al., 1998).  

An alternative indicator to BMI in situations where it is impractical to get weight and height data is the mid-upper arm circumference, which is based on a single anthropometric measure (See Women’s Nutrition indicator ‘Percent of women with low mid-upper arm circumference’).

A related (additional) indicator to BMI is the woman’s weight, which reflects both acute and chronic nutritional stresses. The cut point for identifying women who are undernourished is 45 kg (ACC/SCN, 1992).

Issue(s):

 

BMI may present difficulties to some field workers in service delivery programs because of the mathematical calculations required.  Tools (e.g., tables, wheels) have been developed to assist with these calculations and, more recently, website, computer, and phone applications are available to calculate BMI.  Rapid changes in anthropometric measures as a result of the adolescent growth spurt complicate assessing the nutritional status of those below 18 years of age (i.e., it increases the variance in BMI). Despite this caveat, BMI is recommended for use with adolescents.  

Because BMI varies with body proportions or the Cormic index (sitting height divided by standing height), some have argued that data on sitting height should be collected where possible and that the BMI should be adjusted for the Cormic index.  However, others consider this adjustment to be impractical, given that the calculation of BMI itself is methodologically challenging to some field workers.

Gender Implications:

In cultural settings such as South Asia where women often eat ‘last and least,’ even in households with adequate food available, adolescent and young women may be chronically undernourished. Thus, women frequently enter pregnancy undernourished and become more so throughout pregnancy.  Undernourished pregnant women are at much greater risk of poor birth outcomes than are nourished women. They are more likely to be vitamin A-deficient and to be anemic, both of which also increase the risk of maternal and fetal morbidity and mortality. Education and communication efforts directed toward parents, husbands, mothers-in-law, and communities can address the need to provide more nutritious foods for undernourished girls and women, thereby benefitting their health in the short term and promoting better pregnancy and birth outcomes in the future.

References:

 

ACC/SCN, 1992, Second Report on the World Nutrition Situation, Geneva: ACC/SCN.

Black, RE, Allen, LH, Bhutta, ZA, Caufield LE, de Onis, M, Ezzati, M, Mathers, C, Rivera, J,, “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet 2008; 371: 243-260.

Cnattingius  R, Cnattingius S, Notzon FC, Obstacles to reducing cesarean rates in a low-cesarean setting: the effect of maternal age, height, and weight. Obstet Gynecol. 1998 Oct;92(4 Pt 1):501-6.

Institute of Medicine (IOM) and National Research Council, 2008, Weight Gain during Pregnancy: Reexamining the Guidelines, Eds: Kathleen Rasmussen and Ann Yaktine, Washington, D.C.: The National Academy Press. http://www.ncbi.nlm.nih.gov/pubmed/20669500

Victora, CG, Adair, L, Fall, C, Hallal, PC, Martorell, R, Richter, L, Sachdev, HS, , “Maternal and child undernutrition: consequences for adult health and human capital,”  Lancet 2008; 371: 340–57.

WHO, Maternal anthropometry and pregnancy outcomes: A WHO Collaborative Study, World Health Organization Supplement 1995: 73:32-37.

WHO, 2010, A  Review of Nutrition Policies: Draft Report, Geneva: WHO.

WHO Global Database for Body Mass Index. http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.

Percent of non-pregnant women of reproductive age who have a high body mass index (BMI> 25)

Definition:

The percent of non-pregnant women ages 15 to 49 who have a body mass index (BMI) that is equal to or greater than 25 kg/m2. BMI is the ratio of weight to height squared (kg/m2) and a high BMI measures overweight, and/or obesity in non-pregnant women.

This indicator is calculated as:

(Number of non-pregnant women ages 15 to 49 with a BMI ≥25 / Total number of non-pregnant women between the ages of 15-49) x 100

BMI is calculated as: Weight in kilograms / (Height in meters)2

There are numerous tools (charts, websites, and computer applications) available to calculate BMI. The standard cut-off for overweight in non-pregnant, non-lactating women aged 15-49, determined by WHO (2004) and used by the Institute of Medicine (IOM, 2009) is a BMI of ≥25.

Further refinements in BMI levels of are:

For the full BMI reference table, see WHO Global Database for BMI, 2010.

Data Requirements:

Measurement of weights and heights of non-pregnant women of reproductive age.  Data may be disaggregated by age grouping, levels of overweight and obesity based on WHO cutoffs, by lactation status for postpartum women, and, where data are available, by relevant socioeconomic and demographic factors such as education, income, and urban/rural residence.

Data Sources:

Population-based surveys; surveillance systems; health facility records

Purpose:

 

A well-accepted measure of weight status, BMI is a self-contained ratio highly correlated with weight-for-height that does not require reference tables for interpretation.  Although this indicator specifies non-pregnant women, BMI during early pregnancy also is commonly used to identify women who need to gain more or less weight in order to improve pregnancy outcomes. This indicator relates to two of the Millennium Development Goals: #4. Reduce child mortality; and #5. Improve maternal health. 

Overweight and obesity is a growing problem worldwide and part of a “double burden” of health concerns stemming from the co-existences of under- and overnutrition in many regions.  While rates of underweight children in Africa have not fallen between 1990 and 2010, rates of overweight have doubled (WHO, 2010).  The highest rates of overweight for women are found in Central America (67%) and the Federated States of Micronesia (62%).  (Note: For regional and national BMI surveillance data, see WHO Global Database for BMI.

Overnutrition is a form of malnutrition and, depending on the types and amounts of foods consumed, can be associated with diets high in processed calorie-dense foods, yet deficient in key nutrients, vitamins and minerals. Overweight adolescent girls and women are at increased risk for a number of chronic diseases including cardiovascular disease, type 2 diabetes, hypertension, stroke, and some cancers in addition to elevated risk for pregnancy complications and poor birth outcomes.  Based on a meta-analysis from developed and developing countries, MacDonald et al. (2010) found that overweight and obese women have increased risks of preterm birth.  Maternal obesity has been found to be associated with increased incidence of pre-eclampsia, gestational hypertension, macrosomia, stillbirth, induction of labor and caesarean delivery (Bhattacharya, et al., 2007).  Higher BMI among women with short stature is a risk factor for pregnancy complications and the need for assisted delivery (Cnattingius et al., 1998).

Issue(s):

 

BMI may present difficulties to some field workers in service delivery programs because of the mathematical calculations required.  Tools (e.g., tables, wheels) have been developed to assist with these calculations and, more recently, website, computer, and phone applications are available to calculate BMI.  Rapid changes in anthropometric measures as a result of the adolescent growth spurt complicate assessing the nutritional status of those below 18 years of age (i.e., it increases the variance in BMI). Despite this caveat, BMI is recommended for use with adolescents.  

Because BMI varies with body proportions or the Cormic index (sitting height divided by standing height), some have argued that data on sitting height should be collected where possible and that the BMI should be adjusted for the Cormic index.  However, others consider this adjustment to be impractical, given that the calculation of BMI itself is methodologically challenging to some field workers.

References:

Bhattacharya, Sohinee, Campbell, DM, Liston WA, and Bhattacharya Siladitya, Effect of Body Mass Index on pregnancy outcomes in nulliparous women delivering singleton babies,  BMC Public Health 2007, 7:168 doi:10.1186/1471-2458-7-168.

Cnattingius  R, Cnattingius S, Notzon FC, Obstacles to reducing cesarean rates in a low-cesarean setting: the effect of maternal age, height, and weight. Obstet Gynecol. 1998 Oct;92(4 Pt 1):501-6.

MacDonald SD, Han Z, Mulla S, Beyene J, Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and metananlysis, BMJ 2010:341:c3428.

WHO Global Database for Body Mass Index, http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.

WHO, 2010, A  Review of Nutrition Policies: Draft Report, Geneva: WHO.

WHO, Maternal anthropometry and pregnancy outcomes: A WHO Collaborative Study, World Health Organ Suppl 1995: 73:32-37.

Percent of women with a low mid-upper arm circumference (<22.5)

Definition:

The percent of women with a mid-upper arm circumference (MUAC) below 22.5 cm (ACC/SCN, 1992).

This indicator is calculated as:

(Number of women ages 15 to 49 with mid upper arm circumference <22.5cm / Total number of women between the ages of 15-49) x 100

For a related MUAC indicator used to screen women with HIV, see “Percent of HIV positive women who have mid-upper arm circumference <21 at first postnatal visit within 6 weeks of delivery,” in section on Women’s Nutrition and HIV and A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV (Fanta, 2010).

Data Requirements:

A measure of MUAC in women of reproductive age (15-49). Data can be disaggregated by age grouping, reproductive status, and, where available, relevant socioeconomic and demographic factors such as education, income, and urban/rural residence.

Data Sources:

DHS or other population-based surveys; health facility records. 

Purpose:

The measurement of MUAC is commonly used as an indicator of malnutrition and wasting in children.  MUAC can be used as an indicator of maternal nutritional status in non-pregnant women because of its high correlation with maternal weight and weight for height, as well as, during pregnancy to screen for risk of low birth weight and perinatal mortality (Krasoved and Anderson, 1991).  Increases of MUAC during pregnancy are generally less than .05 cm and it can be considered a proxy indicator for women’s pre-pregnancy or early pregnancy weight (Krasovec and Anderson, 1991; WHO 1995).  The same cut-off value can be used to define undernutrition in both pregnant and non-pregnant women because of the slight change of values change during pregnancy.  Since MUAC is correlated with pre-pregnancy weight, it may be useful for identifying pregnant women at risk of IUGR, especially where scales are not available (WHO, 1995).

MUAC is easily obtained in clinical settings or during population-based surveys.  The measuring tapes are portable and inexpensive, and persons with limited education or experience can learn to take this measurement accurately. The measurement of MUAC not only yields useful data, but also raises awareness about nutritional status among those participating in the study.  MUAC is used primarily for screening, because it changes slowly in large populations.  However, it is potentially useful for evaluating the impact of interventions in a given (limited) population.  In settings with limited infrastructure and resources, MUAC may be the most feasible anthropometric indicator to use.

Issue(s):

MUAC is primarily used for screening rather than evaluation purposes. Although the correlation between MUAC and pre-pregnancy weight is statistically significant, the association is considered too weak to allow MUAC to be substituted for pre-pregnancy weight in individuals (WHO 1995).  While the value of MUAC >33 has been used to identify overweight, the cutoff has not been validated for women and pregnancy outcomes.

References:

ACC/SCN, 1992, Second Report on the World Nutrition Situation, Geneva: ACC/SCN.

FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development. http://www.fantaproject.org/publications/Screening4FNS.shtml

Krasovec, K. and M. Anderson, eds. (1991). Maternal nutrition and pregnancy outcomes: anthropometric assessment. Pan American Health Organization: Scientific Publication No 529.

WHO, Maternal anthropometry and pregnancy outcomes: A WHO Collaborative Study, World Health Organization Supplement 1995: 73:32-37.

Percent of service delivery points with adequate supplies of mineral/vitamin supplements

Definition:

The percent of service delivery points (SDPs) with adequate supplies of quality mineral and vitamin supplements at the time of data collection.

This indicator is calculated as:

(Number of SDPs with an adequate supply of quality mineral/vitamin supplements /  Total number of SDPs) x 100

Adequate supply is defined as availability of sufficient quantity and quality of mineral/vitamin supplements based on the needs of the client population served.  The basic mix of supplements will include iron and folic acid, vitamin A, iodine and zinc in forms ranging from tablets and drops to injectables.  Additional types may include vitamins B12 and D, calcium, and multiple vitamin and mineral supplement preparations.  Evaluators should calculate each type of supplement separately, because the frequency of doses and, therefore, the amount necessary depend on the type of supplement (i.e., daily or weekly iron/folate supplements vs. single postpartum dose of vitamin A) and because some products are more difficult to procure or store in a given country or setting (Gorstein et al., 2007).

To compute sufficient quantity, evaluators estimate the size of the catchment area and the subgroup within that area in potential need of each supplement.  Next, evaluators calculate the average quantity of each supplement needed per recipient in the target population for a specific reference period. This approach allows a crude calculation of the ‘sufficient quantity’ for each supplement relative to the client population served. There is no universally accepted standard for measuring adequate supplies; however, evaluators should consider the type of supplement, the frequency of supply, and the amount of supply available at the SDP when they define adequate quantities of supplies.

The quality of the mineral/vitamin supplement supply is acceptable if the supplements are:

Examples of additional criteria for quality of specific supplements are:

Data Requirements:

A count of the number of SDPs in the catchment area; a count of the potential client population(s) in the catchment area served at each SDP; a count of units of each supplement listed by form of the supplement (e.g., iron: tablets and drops; iodine: tablets and injectables; vitamin A: high- and low-dose capsules) of acceptable quality at the SDP; the volume of supply of each mineral/vitamin in terms of individual doses; and number of doses of each supplement judged to be both sufficiently well stocked and of adequate quality.

Data Sources:

Program records indicating the number of SDPs and the population in the catchment area; the inventory of each SDP (special study) and inspection of each unit of supplement to determine the number of supplements that are of acceptable quality.

Purpose:

A number of vitamins and minerals (also known as micronutrients) are particularly important because they are essential for good health, growth and successful birth outcomes, and because large numbers of girls and women of reproductive age are deficient in them (Micronutrient Initiative [MI], 2009). These micronutrients include vitamin A, iodine, zinc, iron and folate.  More recently, vitamin D, calcium, and vitamin B12 are being included for distribution in a number of regions and sites (Black et al., 2008).  Access to adequate and safe supplies of micronutrients pre-pregnancy, during pregnancy and postpartum provides cost-effective health and survival protection for vulnerable populations of adolescent girls, women, and their offspring.  The 2008 Copenhagen Consensus panel ranked the provision of micronutrients as the world’s best investment for development (MI, 2009). This indicator relates to three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health.

This indicator is important at the program level to evaluate the extent SDPs have supplements that are both available and of acceptable quality to meet clients’ nutritional needs. This indicator requires that the supplements meet both criteria of adequate quantity and of sufficient quality and evaluators need to assess the results of these two factors simultaneously to determine if a given SDP has an adequate supply.

An additional process indicator of the adequacy of supply is the frequency of stockouts (i.e., the percentage of SDPs that experience a stockout of supplements at least once over a 12-month period). For additional discussion on indicators for measuring supplies and stockouts, see the database section on Commodities, Security, and Logistics..

Issue(s):

This indicator measures the presence of products at service delivery facilities. It does not, however, measure the effective distribution of these products to the intended beneficiaries. Staff awareness, motivation, and training will strongly influence this process. Assessment of facilities’ adequate storage and handling of supplements at the time of surveys may not capture the quality of the supply chain or ensure that there have not be lapses, such as, exposure to sunlight or  electrical outages affecting cold storage.

The indicator applies to health service delivery points and may not include other sources for supplements, such as, local pharmacies and community based distribution mechanisms, thereby potentially underestimating supplies. The MI/CDC (Gorstein et al., 2002) indicators for micronutrient interventions include ‘selling facilities’ in measuring supplement availability.

References:

Black, RE, Allen, LH, Bhutta, ZA, Caufield LE, de Onis, M, Ezzati, M, Mathers, C, Rivera, J,, “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet 2008; 371: 243-260.

Gorstein J, Sullivan KM, Parvanta I, Begin F. Indicators and Methods for Cross-Sectional Surveys of Vitamin and Mineral Status of Populations. The Micronutrient Initiative (Ottawa) and the Centers for Disease Control and Prevention (Atlanta), May 2007.  http://www.who.int/vmnis/toolkit/mcn-micronutrient-surveys.pdf

The Micronutrient Initiative (MI), 2009, Investing in the future: A united call to action on vitamin and mineral deficiencies, Canadian International Development Agency. Ottawa.

Percent of pregnant women who receive the recommended number of iron/folate supplements during pregnancy

Definition:

The percent of women with a birth in the last two years who received or bought iron/folic acid supplements for at least six months during their last pregnancy in amounts that were in accordance with recommended protocols.

This indicator is calculated as:

(Number of pregnant women who received or purchased the recommended number of iron/folic acid tablets during last pregnancy /Total number of pregnant women with a birth in last two years) x 100

The current WHO recommendations are 60 mg of iron and 400 ug folic acid daily during pregnancy for all women, beginning as soon as possible during gestation and no later than the third month (WHO, 2010; WHO, 2011).

Data Requirements:

Information on the number of pregnant women who were issued or who purchased iron/folate tablets during last pregnancy; the number of tablets issued or purchased; and the total number of women who gave birth in the reference period

Data Sources:

Health facility and antenatal care (ANC) clinic records; population based surveys (e.g., DHS, RHS, UNICEF Multiple Indicator Cluster Surveys)

Purpose:

This indicator measures the percentage of women who received or purchased the recommended amounts of supplements for iron and folic acid during pregnancy.  It provides information about the quality of ANC services and/or women’s access to purchasing supplements through local pharmacies and community-based sources.

Iron deficiency is a common nutrient deficiency and the resulting iron deficiency anemia is a major contributor to the global burden of disease (WHO/CDC, 2008). Anemia is a common problem among women of reproductive age, especially in low and middle income countries where low dietary intake of bioavailable iron combined with endemic infectious diseases such as helminthiasis puts women at increased risk in the preconception period. Low preconception hemoglobin and ferritin levels increase the risk of poor fetal growth and low birth weight (Dean, Lassi, Imam and Bhutta, 2014). Anemia during pregnancy (hemoglobin levels < 11g/dl) is associated with increased risks for maternal mortality, premature birth, and low birth weight.  Pregnant women need iron to support their enlarged blood volume, to provide for placental and fetal needs,and to replace blood loss in childbirth.  The fetus relies on maternal iron stores to create adequate reserves of its own, which in tandem with the iron in breast milk, will meet the iron needs of the normal birth weight infant through the first six months of life.  The 2008 Copenhagen Consensus panel ranked the provision of micronutrients, including iron and folic acid, as the world’s best investment for development (Micronutrient Initiative [MI], 2009). This indicator relates to three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health. 

Iron supplementation is universally recommended during the second and third trimesters when iron stores become depleted over the course of pregnancy (WHO, 2010; MI, 2009).  The high physiologic requirement for iron during pregnancy is difficult to meet with most diets even where more iron-rich foods are available (INACG/WHO/UNICEF, 1998).  Providing iron/folate supplements for women pre-pregnancy or early in the pregnancy is desirable, particularly where deficiency levels are high (≥40%).  Because the efficiency of absorption of iron increases as iron deficiency anemia becomes more severe, the recommended 60 mg dose should provide adequate supplemental iron to women who do not have clinically severe anemia if it is given for an adequate duration.  

Guidelines for treating severe anemia in pregnant women (Hg <7g/dl) includes three months of therapeutic supplementation (120 mg iron and 400 ug folic acid) followed by the preventive regimen (60 mg iron and 400 ug folic acid) for the duration of pregnancy and three months postpartum (INACG/WHO/UNICEF, 1998).  Complementary parasite control measures and dietary counseling are also recommended.

Supplementation with 400 µg of folic acid around the time of conception significantly reduces the incidence of neural tube defects.  These defects cause serious disabilities and infant mortality, and commonly arise in the first weeks of pregnancy before a woman may realize she is pregnant.  Folate supplementation begun after the first trimester of pregnancy is too late to prevent birth defects.  A daily dose of 400 µg folic acid is considered a safe and healthy intake for women during pregnancy and lactation but is more than the amount required to produce an optimal hemoglobin response in pregnant women.

An alternative indicator that reflects the adequacy of the program in meeting the needs of specific clients is ‘Number of iron/folate tablets distributed per eligible client.’

Issue(s):

This indicator captures the distribution of iron/folate supplements, but not the actual consumption. Clients must receive appropriate counseling on why and how to take iron/folate supplements.  The best practice is for iron/folate supplementation to begin before pregnancy, but this indicator is primarily intended to measure supplementation during the last two trimesters of pregnancy.  Accurate reporting of the numbers of supplements received or purchased by women is problematic, even when measured specifically for the second and third trimesters of pregnancy.  Heath facility client records may not be consistently accurate.  Some women may be purchasing supplements from community-based pharmacies and other sources and their recall for amounts purchased may be subject to error.

References:

Dean SV, Lassi ZS, Imam AM, and Bhutta ZA. "Preconception care: nutritional risks and interventions". Reproductive Health Volume 11 Supplement 2, 2014: Preconception interventions. 

International Nutritional Anemia Consultative Group (INACG), WHO, UNICEF, 1998, Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia, Ed. Rebecca J. Stoltzfus, Michele L. Dreyfuss.

The Micronutrient Initiative (MI), 2009, Investing in the future: A united call to action on vitamin and mineral deficiencies, Canadian International Development Agency. Ottawa.

WHO, Nutrition Landscape Information System (NLIS) 2010, Country Profile Indicators Interpretation Guide, Geneva: WHO. http://whqlibdoc.who.int/publications/2010/9789241599955_eng.pdf  

WHO, 2011, Evidence-Informed Guidelines: Daily iron and folic acid supplementation in pregnant women, Geneva: WHO. https://www.ncbi.nlm.nih.gov/books/NBK132263/

WHO/CDC. 2008. Worldwide prevalence of anaemia 1993–2005 : WHO global database on anaemia. De Benoist B, McLean E, Egli I, Cogswell M eds. World Health Organization, Geneva. Available at http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

Anemia testing included as component of basic antenatal care package

Definition:

The number or percent of facilities that provide anemia testing for pregnant women as part of a basic antenatal care (ANC) package.

This indicator is calculated as:

(# of facilities that provide anemia testing as part of basic ANC/Total # of facilities providing basic ANC) x 100

 Evaluators may weight results by client volume.

Anemia is tested by measuring blood hemoglobin concentration.  The gold standard for assessing hemoglobin is the direct cyanomethhemoglobin method, which requires access to a laboratory. However, indirect methods using a finger-prick blood sample can be administered as a low technology alternative.  In areas where resources are lacking for the test kits, ANC clinics can screen for anemia by clinical examination using a WHO developed color scale comparing the shade or color shade of blood with defined hues of red(WHO, 2006).

Data Requirements:

Total number of ANC clinics in a specified area and number of ANC clinics that provide anemia testing as part of basic ANC package; optional review of local and national policies on guidelines for basic ANC package and inclusion of anemia testing.

Data Sources:

Health facility and ANC clinic records; staff and exit interviews and observations; local and national policies for basic ANC care best practices.

Purpose:

This indicator measures the extent to which ANC clinics include testing for anemia in basic ANC care for all clients.  The level of screening for anemia can serve as a proxy for the quality of ANC services. Testing for anemia, provision of iron/folate supplements during pregnancy, and treatment for moderate to severe anemia are standard best practices in ANC (USAID/CORE, 2004; CARE/CDC, 2003). This indicator relates to two of the Millennium Development Goals: #4. Reduce child mortality; and #5. Improve maternal health.  

Anemia is a condition in which an inadequate number of red blood cells or an inadequate amount of hemoglobin impairs blood oxygen transport resulting in reduced physical and mental capacity. Among women of reproductive age, adolescent girls and pregnant women are at most risk for anemia: adolescents because of the onset of menstruation and pregnant women because of the increased blood volume associated with pregnancy.  Anemia in pregnant women is defined as a hemoglobin concentration <11 g/dl.  Based on a WHO review of nationally representative samples from 1993 to 2005, 42 percent of pregnant women have anemia, and 60 percent of this anemia is assumed to be due to iron deficiency in non-malarial areas and 50 percent in malarial areas (WHO/CDC, 2008).  In industrialized countries anemia also affects women, especially those of lower socioeconomic status. Iron deficiency is the primary cause of most anemia in low-income environments. Severe anemia among pregnant women resulting from iron deficiency is associated with an increased risk of maternal and fetal mortality and morbidity and of intrauterine growth retardation (WHO, 2000; WHO/CDC, 2008).

Issue(s):

Ideally, all ANC services in a specified area would be included in a survey.  However, for a large catchment area, this may not be practical and sampling can be adopted. Screening for anemia does not indicate if pregnant women are given the universally recommended doses of iron/folate supplements during their ANC visit and more specialized counseling and treatment for cases of moderate to severe anemia.

References:

CARE/CDC, 2003, The Healthy Newborn: A reference manual for program managers, J. Lawn, B. McCarthy, S.R. Ross. Atlanta, Georgia: CARE/CDC Health Initiative.

USAID/CORE, 2004, Maternal and newborn standards and indicators compendium, http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

WHO, 2006, Reproductive health indicators; guidelines for their generation, interpretation, and analysis, Geneva: WHO. http://apps.who.int/iris/bitstream/10665/43185/1/924156315X_eng.pdf

WHO/CDC. 2008. Worldwide prevalence of anaemia 1993–2005 : WHO global database on anaemia. De Benoist B, McLean E, Egli I, Cogswell M Eds. World Health Organization, Geneva. Available at http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

Percent pregnant women tested for anemia

Definition:

The proportion of pregnant women who were tested for anemia during their antenatal care (ANC) visit.

This indicator is calculated as:

(# pregnant women who were tested for anemia during pregnancy/Total # of pregnant women attending ANC) x 100

Anemia is tested by measuring blood hemoglobin concentration.  The gold standard for assessing hemoglobin is the direct cyanomethhemoglobin method, which requires access to a laboratory. However, indirect methods using a finger-prick blood sample can be administered as a low technology alternative.  In areas where resources are lacking for the test kits, ANC clinics can screen for anemia by clinical examination using a WHO developed color scale comparing the shade or color shade of blood with defined hues of red(WHO, 2006).

Data Requirements:

The number of pregnant women attending ANC clinic during a reference period (e.g., one year) and the number who were tested for anemia during the same reference period.

Data Sources:

Clinic registries; ANC records and cards.  Health facility exit interviews and provider observations can be useful for evaluation purposes but not for ongoing monitoring. 

Purpose:

This indicator measures the extent to which ANC clients are screened for anemia and can serve as a proxy for the quality of ANC services. Testing for anemia, provision of iron/folate supplements during pregnancy, and treatment for moderate to severe anemia are standard best practices in ANC (USAID/CORE, 2004; CARE/CDC, 2003).  This indicator relates to two of the Millennium Development Goals: #4. Reduce child mortality; and #5. Improve maternal health.

Anemia is a condition in which an inadequate number of red blood cells or an inadequate amount of hemoglobin impairs blood oxygen transport resulting in reduced physical and mental capacity. Among women of reproductive age, adolescent girls and pregnant women are at most risk for anemia: adolescents because of the onset of menstruation and pregnant women because of the increased blood volume associated with pregnancy.  Anemia in pregnant women is defined as a hemoglobin concentration <11 g/dl.  Based on a WHO review of nationally representative samples from 1993 to 2005, 42 percent of pregnant women have anemia, and 60 percent of this anemia is assumed to be due to iron deficiency in non-malarial areas and 50 percent in malarial areas (WHO/CDC, 2008).  In industrialized countries anemia also affects women, especially those of lower socioeconomic status. Iron deficiency is the primary cause of most anemia in low-income environments. Severe anemia among pregnant women resulting from iron deficiency is associated with an increased risk of maternal and fetal mortality and morbidity and of intrauterine growth retardation (WHO, 2000; WHO/CDC, 2008).

Issue(s):

Screening for anemia does not indicate if pregnant women are given the universally recommended doses of iron/folate supplements during their ANC visit and more specialized counseling and treatment for cases of moderate to severe anemia. Guidelines for treating severe anemia in pregnant women includes three months of therapeutic supplementation (120 mg iron and 400 ug folic acid) followed by the preventive regimen (60 mg iron and 400 ug folic acid) for the duration of pregnancy and three months postpartum (INACG/WHO/UNICEF, 1998).  Complementary parasite control measures and dietary counseling are also recommended.

Women attending ANC may be a self-selected group and not representative of all pregnant women in an area. They may be more likely to have health problems or to be more affluent, educated, and/or urban.  If data sources are from routine ANC screening, caution should be used in interpreting and generalizing results.

References:

CARE/CDC, 2003, The Healthy Newborn: A reference manual for program managers, J. Lawn, B. McCarthy, S.R. Ross. Atlanta, Georgia: CARE/CDC Health Initiative.

International Nutritional Anemia Consultative Group (INACG), WHO, UNICEF, 1998, Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia, Ed. Rebecca J. Stoltzfus, Michele L. Dreyfuss.

USAID/CORE, 2004, Maternal and newborn standards and indicators compendium, http://www.coregroup.org/storage/documents/Workingpapers/safe_motherhood_checklists-1.pdf

WHO, 2006, Reproductive health indicators; guidelines for their generation, interpretation, and analysis, Geneva: WHO.  http://apps.who.int/iris/bitstream/10665/43185/1/924156315X_eng.pdf

WHO/CDC. 2008. Worldwide prevalence of anaemia 1993–2005 : WHO global database on anaemia. De Benoist B, McLean E, Egli I, Cogswell M eds. World Health Organization, Geneva. Available at http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

Percent of women of reproductive age with anemia

Definition:

The percent of women ages 15 to 49 screened for hemoglobin levels who have inadequate levels.  Pregnant women with a hemoglobin level less than 11g/dl and non-pregnant women with a level less than 12g/dl are considered anemic (WHO, 2001; WHO, 2006).

This indicator is calculated as:

(Number of women ages 15 to 49 with inadequate hemoglobin levels[<12 g/dl non-pregnant women and <11g/dl pregnant women] / Total number of women ages of 15 to 49 screened for hemoglobin levels during a specified period) x 100

WHO (2000) has defined anemia as mild, moderate, or severe based on the following cutoff values (g/dl) for hemoglobin level:

    Mild*    Moderate Severe 
Pregnant 10-10.9   7.0-9.9    <7.0
 Non-pregnant 11-11.9   8.0-10.9  <8.0


*The level of anemia termed ‘mild’ is still a serious condition given iron deficiency is already advanced by the time anemia is detected and deficiency can have functional consequences even when anemia is not clinically apparent (WHO, 2000).

For population-level analyses, evaluators may use mean hemoglobin level (a continuous variable) instead of the above categories of mild, moderate, or severe anemia.

Data Requirements:

 

Hemoglobin concentration measures on a sample of women of reproductive age including both pregnant and non-pregnant women (population based survey, surveillance system, or health facility clients).  The gold standard for assessing hemoglobin is the direct cyanomethhemoglobin method, which requires access to a laboratory. However, indirect methods using a finger-prick blood sample can be administered as a low technology alternative (WHO, 2006).  In areas where resources are lacking for the test kits, antenatal care (ANC) clinics can screen for anemia by clinical examination using a WHO developed color scale comparing the shade or color shade of blood with defined hues of red(WHO, 2006).  Data should be provided with indications of the source (e.g., clinical records, surveys) and the method used for hemoglobin assessment in order to allow for comparisons, when needed.

Data can be disaggregated by age groups, parity, reproductive status (pregnant, lactating, and non-pregnant, non-lactating),  trimester of pregnancy, level of severity of anemia, and where available, by relevant socioeconomic and demographic factors such as education, income, and urban/rural residence.  In addition, altitude can affect hemoglobin levels and may warrant disaggregation or adjustments where wide ranges in altitude exist for a given population (WHO, 2001).

Data Sources:

Population-based surveys (e.g., DHS, RHS, UNICEF Multiple Indicator Cluster Surveys); surveillance (WHO Vitamin and Mineral Information system); health facility data and ANC records.

Purpose:

Anemia is a condition in which an inadequate number of red blood cells or an inadequate amount of hemoglobin impairs blood oxygen transport resulting in reduced physical and mental capacity.  Hemoglobin is the red-pigmented protein in red blood cells that carries oxygen to the brain, muscular system, immune system, and other parts of the body. Iron, folic acid, and other vitamins and minerals (micronutrients) are required for the formation of hemoglobin. Nutrition deficiencies are the most common causes for anemia and iron deficiency anemia is a major contributor to the global burden of disease (WHO/CDC, 2008).  In addition to iron, other nutritional deficiencies (e.g., folate, vitamin B-12, and vitamin A) can cause anemia, as can non-nutritional factors such as acute and chronic infections (malaria, hookworm, HIV) and genetic conditions such as thalassemia and sickle cell trait. This indicator relates to achieving three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health. 

Among women of reproductive age, adolescent girls and pregnant women are at most risk for anemia: adolescents because of the onset of menstruation and pregnant women because of the increased blood volume associated with pregnancy.  Based on a WHO review of nationally representative samples from 1993 to 2005, 42 percent of pregnant women have anemia, and 60 percent of this anemia is assumed to be due to iron deficiency in non-malarial areas and 50 percent in malarial areas (WHO/CDC, 2008).  In industrialized countries anemia also affects women, especially those of lower socioeconomic status. Iron deficiency is the primary cause of most anemia in low-income environments. Severe anemia among pregnant women resulting from iron deficiency is associated with an increased risk of maternal and fetal mortality and morbidity and of intrauterine growth retardation (WHO, 2000; WHO/CDC, 2008).

The initial use for this indicator is to identify women with anemia who require iron supplementation and complementary care.  It can be used as a proxy for general nutritional status.  Population-based assessments can estimate prevalence of anemia and iron deficiency in communities and regions; identify high-risk populations for intervention; monitor prevention or treatment programs; and identify need and advocate for food fortification and iron supplementation programs. For surveillance purposes, rapid assessments of anemia are conducted each year and population–level surveys every five years (WHO, 2006).

This indicator is also useful for monitoring sub-populations (e.g., pregnant women, lactating women, women who receive ANC, women who receive postpartum care) and for evaluating interventions directed towards these subgroups.

Issue(s):

 

Various factors may influence estimates of anemia prevalence, including sex, age, pregnancy status, smoking status and altitude. Atmospheric oxygen levels fall with increasing altitude, thereby leading to higher blood hemoglobin levels.  Evaluators should adjust individual-level for data long-term altitude exposure (see WHO, 2001, Annex 3 for altitude adjustment values).

Low hemoglobin levels may be due to multiple causes, such as, short birth intervals, blood loss, or illnesses that are not nutrition related. Additional laboratory tests, such as measurement of serum ferritin and/or malarial and parasitic egg counts, are necessary to determine if iron deficiency is the primary cause of the anemia. However, these tests are frequently impractical for field-based use.  Until a simple, cost-effective test for measurement of iron deficiency is widely available for program and field applications, the prevalence and distribution of anemia will continue to be used to estimate the extent, trends, and severity of both anemia and iron deficiency anemia at the population level.

Women attending ANC may be a self-selected group and not representative of all pregnant women in an area. They may be more likely to have health problems or to be more affluent, educated, and/or urban.  If data sources are from routine ANC screening, caution should be used in interpreting and generalizing results.

Gender Implications:

There may be gender-related food taboos that contribute to high levels of anemia by denying women iron-rich foods (meat, eggs, and dairy). In addition, social norms may dictate the order in which family members eat, thus limiting women’s (especially girls and young women) access to iron-rich foods.  It may be difficult for women to obtain iron/folate supplements if they lack freedom of movement to travel to distribution points or lack access to household financial resources for transportation to distribution points or to purchase commodities.

References:

 

WHO, Vitamin and Mineral Information System (VMNIS), Department for Health and Development (NHD), Geneva, Switzerland. Online database at http://www.who.int/vmnis/en/

WHO, 2000, The management of nutrition in major emergencies, Geneva: WHO. 

WHO, 2001, Iron deficiency anaemia, assessment, prevention, and control: A guide for program managers, Geneva: WHO.

WHO, 2006, Reproductive health indicators; guidelines for their generation, interpretation, and analysis, Geneva: WHO.  http://apps.who.int/iris/bitstream/10665/43185/1/924156315X_eng.pdf

WHO/CDC. 2008. Worldwide prevalence of anaemia 1993–2005 : WHO global database on anaemia. De Benoist B, McLean E, Egli I, Cogswell M eds. World Health Organization, Geneva. Available at http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

Percent of women living in households using adequately iodized salt

Definition:

 

The percent of women who live in households using salt that has been fortified with iodine according to recommended standards.  ‘Adequately iodized salt’ is defined as salt containing ≥15 ppm of iodine.

This indicator is calculated as:

(Number of women who live in households with salt containing ≥15 ppm iodine / Total number of women surveyed) x 100

Data Requirements:

 

Results of testing household salt used for cooking and/or as table salt.  For accurate testing, household samples of salt should be sent to laboratories for titration testing that can determine concentration levels (WHO, 2001). Rapid test kits have been designed for screening and can indicate if iodine is present in a sample, but do not give a reliable measure of concentration.  The rapid test kits lack the necessary sensitivity and specificity for calculating this indicator (Gorstein, et al., 2007). Household salt iodine levels can be categorized as adequate or inadequate and, where found, as excessive.  Household surveys also can collect data on brand names, dates of expiration, and the presence or absence of iodization labeling (ACC/SCN, 2007). Where available, data can be disaggregated by geographic/ecological zone and relevant socioeconomic and demographic factors such as education, income, and urban/rural residence

Data Sources:

 

Population-based household surveys; the testing of households using iodized salt is part of the core questionnaire in the DHS and UNICEF-MICS.

Purpose:

 

This indicator serves as a proxy measure for the number of women who may be receiving adequate amounts of iodine.  Iodine deficiency disorders (IDD) are prevalent throughout the world and an estimated two billion people have inadequate iodine intake (Gorstein et al., 2007).  The most at-risk populations for low iodine intake live in remote inland areas where no marine foods are eaten.  IDD interventions often focus on women of reproductive age because of their increased need for iodine during pregnancy.  Iodine deficiency in pregnancy can cause extreme and irreversible mental and physical retardation known as cretinism.  Even milder, subclinical deficiencies can impair fetal motor and mental development and are associated with miscarriage, fetal growth restriction, stillbirth (ACC/SCN, 2007; Black et al., 2008; WHO, 2010).  Mild deficiency among children and adults is very common and can cause loss of learning ability and goiter (an enlargement of the thyroid gland).  Iodine deficiency alone was found to lower mean IQ scores by 13.5 points (Bleichrodt and Born, 1994).  For pregnant women with severe deficiencies, iodine supplementation by the second trimester can improve neurological and cognitive development of the infant (Black et al., 2008).  This indicator relates to achieving Millennium Development Goals: #4. Reduce child mortality; and #5. Improve maternal health. 

This indicator can be used to evaluate the availability of adequately iodized salt in households for a given population.  The coverage indicator for the ‘proportion of households having access to iodized salt’ is included in the DHS core survey, UNICEF–MICS, and is used for surveillance in the Vitamin and Mineral Nutrient Indicator (VMNIS) database. WHO and UNICEF have recommended universal salt iodization (USI) as a safe, cost-effective and sustainable approach to ensure sufficient iodine intake and reduce the burden of disease associated with iodine deficiency (ACC/SCN, 2007).  

Additionally, this indicator can be a proxy for iodine status, however, the primary indicator for measuring iodine status and determining IDD is urinary iodine concentration (UI).  For pregnant women, UI levels below 150 mcg/L are considered inadequate and above 500 mcg/L are considered excessive.  An additional adequacy criterion is that not more than 20 percent of UI samples from children and non-pregnant women are below 50 mcg/L of iodine.  More details on indicators for iodine coverage and status can be found in these resources: WHO (2010); Gorstein et al. (2007); and WHO/UNICEF/ICCIDD, (2001).

Issue(s):

 

In measuring household availability of iodized salt for women in the sample, the indicator does not reflect the women’s actual intake of iodine or their physiologic iodine status.  Households’ salt supplies may be from varying sources, some of which are iodized and others not, or the salt processing facilities may not be consistent in the levels of iodine added.  For women with severe IDD, household availability of iodized salt may not provide sufficient iodine needed during pregnancy and supplementation may be needed.

Accurate testing for iodine levels is costly and requires sending samples to a laboratory.  The rapid test kits can detect the presence of iodine in salt but do not provide information on the level and whether it is adequate or excessive.

References:

 

ACC/SCN, 2007, ‘Universal Salt Iodization,’ SCN News; No. 35, Geneva: WHO.

Black, RE, Allen, LH, Bhutta, ZA, Caufield LE, de Onis, M, Ezzati, M, Mathers, C, Rivera, J,, “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet 2008; 371: 243-260.

Bleichrodt, N., and M. Born. 1994. "A Meta-Analysis of Research into Iodine and Its Relationship to Cognitive Development." In The Damaged Brain of Iodine Deficiency, ed. J. B. Stanbury, 195-200. New York: Communication Corporation.

Gorstein J, Sullivan KM, Parvanta I, Begin F. Indicators and Methods for Cross-Sectional Surveys of Vitamin and Mineral Status of Populations. The Micronutrient Initiative (Ottawa) and the Centers for Disease Control and Prevention (Atlanta), May 2007.  http://www.who.int/vmnis/toolkit/mcn-micronutrient-surveys.pdf

WHO, UNICEF, International Council for the Control of Iodine Deficiency Disorders (ICCIDD), 2001, Assessment of iodine deficiency disorders and monitoring their elimination, WHO/NHD/01.01 , Geneva:WHO.

WHO, 2010, Nutrition Landscape Information System (NLIS), Country Profile Indicators Interpretation Guide, Geneva: WHO. http://whqlibdoc.who.int/publications/2010/9789241599955_eng.pdf   

WHO, Vitamin and Mineral Information System (VMNIS), Department for Health and Development (NHD), Geneva, Switzerland. Online database at http://www.who.int/vmnis/en/

Percent of women with a live birth in the last two years who received high-dose Vitamin A within eight weeks (six weeks if not breastfeeding) of their last live birth

Definition:

 

The most recent WHO evidence-based guideline is that postpartum vitamin A supplementation is not recommended for the prevention of maternal and infant morbidity and mortality. Rather women should be encouraged to receive adequate nutrition which is best achieved through consumption of a balanced healthy diet. However, recommendations for treatment of xerophthalmia are not covered in this guideline (WHO, 2011).

 

The percent of women with a live birth in the previous two years who received postpartum high dose supplements (200,000 IU per dose) of vitamin A (retinyl palmitate)within eight weeks for breastfeeding women or within six weeks for non-breastfeeding women.

This indicator is calculated as:

(Number of women who received postpartum high-dose Vitamin A within 8 weeks (breastfeeding) or 6 weeks (non-breastfeeding) of last live birth / Total number of women with live birth in last 2 years) x 100

Data Requirements:

 

The total number of births during a given reference pe­riod and the number of women receiving two high-dose vitamin A supplements within six or eight weeks of delivering depending on breastfeeding status.  Evaluators should disaggregate findings for lactating versus non-lactating women (to ensure that the program is reaching both groups), by age groups, parity and, where available, by relevant socioeconomic and demographic factors such as education, income, and urban/rural residence.

Data Sources:

 

Program statistics (usual source); population-based surveys (e.g. DHS, UNICEF-MICS)

Purpose:

 

High-dose vitamin A supplementation early postpartum helps replace maternal stores used up during pregnancy and raises or maintains the concentration of vitamin A in the breast milk of lactating women with vitamin A deficiency (VAD).  Based on serum retinol levels from 406 surveys conducted between 1995 to 2005, WHO (2009) estimated 19.1 million pregnant women (15.3 percent) worldwide are at risk for VAD. In addition to contributing to maternal mortality and other poor outcomes of pregnancy and lactation, VAD diminishes the body’s ability to fight infections and is a risk factor for anemia. In its more severe forms, VAD can lead to night blindness in children and pregnant women and to blindness through progressive drying, ulceration, and necrosis of the cornea. The main underlying cause of VAD is a diet that is chronically insufficient in vitamin A and B-carotene that can lead to reduced body stores and fail to meet basic physiologic needs, such as, supporting tissue growth, normal metabolism, and resistance to infection.  This indicator can be used as a proxy for the coverage and quality of postpartum care and relates to three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health. 

Mega-doses of vitamin A can potentially harm a fetus, therefore, women who could become pregnant must not receive high doses of vitamin A. WHO recommends a single oral dose of 200,000 iu in the early postpartum period to minimize the risk of a woman being pregnant.  The recommended time frames are prior to 8 weeks for breastfeeding women and prior to 6 weeks for non-breastfeeding women (WHO, 2009). The dose of 200,000 iu is considered sufficient to raise and maintain the vitamin A content of breast milk and to offset the depleting effect lactation may have on the mother’s own vitamin A stores.  The International Vitamin A Consultative Group (IVACG) reports on a series of studies that compared the single mega-dose of vitamin A with a second 200,000 iu dose within the recommended time frame and no significant differences were found at 6 months for breast milk retinol or the prevalence of VAD (IVACG, 2004). 

An alternative indicator reflecting the adequacy of the program in meeting the needs of specific clients is the number of capsules distributed per eligible client.

Issue(s):

 

A potential problem in the calculation of this indicator is the clients may deliver at a different place from the one where they receive the supplementation. If the indicator is based on an overall figure for a district, it is generally more accurate than if it were based on the data from specific clinics. Similarly, it is important to specify whether this indicator measures supplements distributed through outreach workers to mothers delivering at home, or only those given at service delivery points.  If heath facility client records or community-based distribution records are used, these may not be consistently accurate. 

Because there have been varying recommendations about the number and timing of the postpartum vitamin A mega-doses, women’s recall from their last live birth in the past two years may be biased by the dosing regimen.  Women who received two mega-doses may be more likely to remember than those who received one.

References:

 

IVACG, 2004,Vitamin A and the common agenda for micronutrients, Report of the XXII IVACG Meeting, Lima, Peru: Nov. 15-17.

WHO, 2011, Evidence-Informed Guidelines: Vitamin A Supplementation in Postpartum Women, Geneva: WHO. http://apps.who.int/iris/bitstream/10665/44623/1/9789241501774_eng.pdf

WHO, 2009, Global prevalence of vitamin A deficiency in populations at risk 1995-2005: WHO database on vitamin A deficiency, Geneva: WHO.

Percent of women with low serum vitamin A concentration

Definition:

The percent of women ages 15 to 49 who were tested for serum vitamin A (retinol) and whose levels were found to be less than 0.70 umol/l for non-pregnant, non-lactating women and less than 1.05 umol/l for pregnant and lactating women. While the cut-off of 1.05 umol/l for pregnant and lactating women is being used on a widespread basis, there is not yet international consensus on this value, and the 0.70 umol/l is used as an alternative cut-off (WHO, 2009). Levels below 0.35 umol/l represent severe vitamin A deficiency (VAD) in children and adults. 

This indicator is calculated as:

(Number of women ages 15 to 49 with low serum vitamin A levels [<1.05 umol/l

pregnant and lactating;  <0.70umol/l non-pregnant, non-lactating] / Total number of women ages of 15 to 49 tested for serum vitamin A) x 100

Data Requirements:

Levels of retinol in serum on a population or subsample of women (note: plasma levels give comparable results, WHO, 1996). The gold standard for analysis of serum retinol levels is high-pressure liquid chromatography (HPLC).  For more detail on serum retinol analysis including the use of dried blood spot samples see: Gorstein et al. (2007); Craft et al. (2000); Klemm et al. (2004).

Levels of serum retinol are affected by infections and subclinical inflammation.  When possible, women’s reports on concurrent infections and fevers and/or blood serum measures of acute phase C-reactive protein are advised.  Data can be disaggregated by age groups, parity, reproductive status (pregnant, lactating, and non-pregnant, non-lactating), trimester of pregnancy, level of severity of VAD, and where available, by relevant socioeconomic and demographic factors such as education, income, and urban/rural residence.  Additionally, season of the year and land ownership have been found to influence vitamin A levels in some low-income populations through access to vitamin A and B-carotene rich foods (IVACG, 2004).

Data Sources:

Population-based surveys (e.g., DHS and UNICEF-MICS); local and program-based studies

Purpose:

VAD contributes to maternal mortality, and other poor outcomes of pregnancy and lactation. It diminishes the body’s ability to fight infections and contributes to anemia. In its more severe forms, VAD can lead to night blindness in children and pregnant women and to blindness through progressive drying, ulceration, and necrosis of the cornea.  Based on serum retinol levels from 406 surveys conducted between 1995 to 2005, WHO (2009) estimated 19.1 million pregnant women (15.3 percent) worldwide are at risk for VAD. The main underlying cause of VAD is a diet that is chronically insufficient in vitamin A and B-carotene that can lead to reduced body stores and fail to meet basic physiologic needs, such as, supporting tissue growth, normal metabolism, and resistance to infection.

Serum retinol has been the indicator used most often in making a biochemical assessment of vitamin A status. WHO has recommended that at least two biologic indicators (i.e., night blindness, biochemical, or histological) be used to determine if VAD exists as a public health problem, rather than relying on a single indicator (Gorstein, 2007). Serum retinol and night blindness during pregnancy are the most likely biological indicators to be collected in cross-sectional surveys, such as, DHS.  This indicator relates to three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health.

Issue(s):

Collecting blood samples is clearly essential for using this indicator. Because the ease of collecting blood samples varies by setting (e.g., it is particularly diffi­cult in populations with high prevalence of HIV), the practicality of this indicator is limited.

Immunoassay of RBP is a lower-cost method compared with serum retinol HPLC and requires a fraction of the amount of serum volume.  Immunoassays of RBP are being compared with serum retinol in dose response studies and in field settings where the methodology is showing promise as a surrogate measure to estimate VAD (PATH, 2005; Fujita at al., 2009). An alternative measure of vitamin A in lactating women is based on vitamin A concentration in breast milk. Breast milk retinol is very useful in evaluating vitamin interventions because it has been shown to be the biochemical indicator most sensitive to measuring the impact of increased vitamin A intakes and supplementation (Stoltzfus and Underwood, 1995). Breast milk retinol levels do not appear to be appreciably influenced by systemic inflammation (Dancheck et al., 2005). However, logistical difficulties in maintaining the sample under the necessary temperature conditions make it less feasible for use in the context of large scale population surveys.

Serum retinol concentrations normally are maintained within a narrow range in individuals with adequate stores of vitamin A in the liver. Thus, low serum retinol can be a useful indicator to identify people with low or depleted liver stores, but provides limited information when body stores of vitamin A are within normal ranges (WHO, 2009). In addition, transient decreases in serum retinol levels due to infections do not reflect changes in liver vitamin A stores and can interfere with use of serum retinol as an indicator.  Because infections and other types of inflammation affect serum retinol levels, measurement of serum CRP or another acute phase protein is advised (Stephensen and Gildengorin, 2000). Hemodilution during pregnancy also affects serum retinol levels, which, in conjunction with increased acute phase proteins during pregnancy, also complicate interpretation. In spite of these limitations at the individual level, serum retinol can be informative for populations.

Simultaneous measurement of CRP is recommended to adjust serum retinol concentrations, particularly in populations with high prevalence of infections.  Again, blood draws for CRP and laboratory costs become a limiting factor, and the assumptions underlying these adjustments can be problematic. Levels of CRP not only increase with age, but are increased during pregnancy (highest in third trimester) in addition to acute phase response to inflammation (Dijkhuizen, 2004). The process of determining serum retinol adjustments for elevated CRP values in adult women and setting cutoffs for elevated CRP and for VAD for pregnant women is complicated by the interactions of these factors.

References:

Craft NE, Bulux J, Valdez C, Li Y, Solomons NW Retinol concentrations in capillary dried blood spots from healthy volunteers: method validation. American Journal of Clinical Nutrition (2000) 72(2):450-4.

Dancheck B, Nussenblatt V, Ricks MO, Kumwenda N, Neville MC, Moncrief DT, Taha TE, Semba RD. Breast milk retinol concentrations are not associated with systemic inflammation among breast-feeding women in Malawi, Journal of Nutrition. 2005 Feb;135(2): 223-6.

Dijkhuizen MA, Wieringa FT, and West CE, Pregnancy affects plasma concentration of retinol and acute phase proteins, Report of the XXII IVACG Meeting, Lima, Peru: November 2004.

Fujita M, Brindle E, Rocha A, Shell-Duncan B, Ndwema P, O’Connor KA, Assessment of the relative dose-response test on serum retinol-binding instead of serum retinol in determining low hepatic vitamin A stores, American Journal Clinical Nutrition, 2009:90:217:217-24.

Gorstein J, Sullivan KM, Parvanta I, Begin F. Indicators and Methods for Cross-Sectional Surveys of Vitamin and Mineral Status of Populations. The Micronutrient Initiative (Ottawa) and the Centers for Disease Control and Prevention (Atlanta), May 2007.  http://www.who.int/vmnis/toolkit/mcn-micronutrient-surveys.pdf

IVACG, 2004, Vitamin A and the common agenda for micronutrients, Report of the XXII IVACG Meeting, Lima, Peru: Nov. 15-17.

Klemm RDW, Christian P, Craft NE, Khatry SK, West KP. Dried Blood Spot (DBS) Retinol Correlates with Serum Retinol and Detects a Response to Vitamin A in Pregnant Nepalese Women, Report of the XXII IVACG Meeting, Lima, Peru: November 2004.

PATH, Retinol binding protein enzyme immunoassay (RDP-EIA), Technology Solutions for Global Health, Nov. 2005.

Stephensen CB and Gildengorin G, Serum Retinol, the acute phase response, and the apparent misclassification of vitamin A status in the third National Health and Nutrition Examination Survey, American Journal Clinical Nutrition 2000;72:1170-8.

Stoltzfus RJ, Underwood BA, 1995, Breast-milk vitamin A as an indicator of the vitamin A status of women and infants, Bulletin of the World Health Organization, 5:703-711.

WHO, 1996, Indicators for Assessing Vitamin A Deficiency and their Application in Monitoring and Evaluating Intervention Programs, WHO Nutrition 96.10. Geneva.

WHO, 2009, Global prevalence of vitamin A deficiency in populations at risk 1995-2005: WHO database on vitamin A deficiency, Geneva: WHO.

Percent of women with night blindness in last pregnancy

Definition:

The percent of women who reported night blindness during their last pregnancy that resulted in a live birth during a specified time period.  The International Vitamin A Consultative Group [IVACG] recommends during the past three years (IVACG, 2002).  Christian (2002) found that Nepali women with live births were more likely to have reported night blindness than women with stillbirths and, to avoid underestimating prevalence, proposed eliciting the history of night blindness only from women whose last pregnancy ended in a live birth.

This indicator is calculated as:

(Number of women who had night blindness during last pregnancy / Total number of women with last pregnancy resulting in live birth during past 3 years) x 100

Maternal night blindness is the inability to see normally after dusk or at night during pregnancy, especially the last trimester and early postpartum.  Night blindness is the most common ocular manifestation of moderate to severe Vitamin A deficiency (VAD) and is evidenced by delayed dark adaptation or difficulty seeing in dim light (IVACG, 2002).  Evaluators need to distinguish and exclude from estimates of prevalence (both the numerator and denominator) women whose blindness was probably due to visual impairment from other causes.

Data Requirements:

Self-report of night blindness during last pregnancy that ended in a live birth. In areas where night blindness exists, qualitative research needs to be conducted to determine the local term or description of symptoms for night blindness in that area. Interviewers and surveys should use local terms for night blindness whenever possible and conduct interviews in a standard manner. Data can be disaggregated by age groups and parity and where available, by relevant socioeconomic and demographic factors such as education, income, and urban/rural residence.

Data Sources:

Population based surveys (e.g., DHS, UNICEF-MICS); local and program-based studies

Purpose: