ÞÍÈÑÅÔ IECD project, Health and Nutrition, UNICEF EVERY MONGOLIAN CHILD HAS THE RIGHT ÒO HEALTHY GROWTH FACTS AND FIGURES Inside: ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ Ulaanbaatar 2002 Infant and Under-Five Mortality Child Malnutrition Vitamin A Deficiency Vitamin D Deficiency Anemia Iodine Deficiency Disorders Breastfeeding Low Birthweight Immunization Maternal Mortality Fertility and Family Planning Rural children have limited access to ARI care Percentage of children with ARI taken to health provider, by residence Mongolia East Asia and Pacific Rural Urban Developing countries 0 20 40 60 80 Integrated Management of Childhood Illnesses About 6860 children aged 0-5 years died in three years (1995-1999) Under five mortality rate is the highest from January to April and the lowest in autumn months. Treatment of children under five suffering from diarrhoea, unsufficient in Northern region Percentage of under-five children with diarrhea, treated by ORS in Mongolia, 2000, by region 75 60 53.9 45 30 59.3 63.3 68.9 National programs for controlling Acute Respiratory Infection and Diarrheal Diseases have certainly played a significant role in the reduction of child mortality rates. There was a 4 fold decrease in the death of children under five from ARI and a 9 fold decrease in the death of children under five from diarrhoeal diseases. Since 1999, the Government of Mongolia has been introducing Integrated Management of Childhood Illnesses (IMCI) with UNICEF and WHO support. The IMCI strategy combines improved management of childhood illnesses with nutrition, immunization and other important factors influencing child health, including maternal health 37.7 Policy Implications and Recommendations 15 0 Northern Western Eastern Central Southern In the countryside, fathers and grandparents play an important role in child care Though parents are the child’s most intimate people, grandparents, elder brothers, and sisters and other relatives also play an important role in caring for children. To improve home care practices through community based activities Continue early stage implementation of IMCI and strengthen ARI/CDD case management Clinical training for soum and family doctors and nurses Follow-up on learning performance Evaluation and consensus meeting, workshop Review meeting at regional and national levels Improve supply of essential supplements Supply of basic medical equipment and IMCI essential drugs Develop IEC materials for health workers and community Develop IEC materials for care providers & for distribution to general public Printing of guideline and training manuals for health workers and for distribution, translation of technical instructions and manuals Provide technical support & capacity building Percentage of under-fives underweight, 2000 65 27 35 30 12 36 14 19 13 34 20 24 33 18 36 36 17 36 11 17 Underweight Stunting The causes of malnutrition § § § § § § Poor knowledge of mothers on child feeding practice and complementary food preparation Lack of information and training for mothers on the importance of adequate feeding for infants Inappropriate commitment of health workers to inform and train young and pregnant women and lactating mothers on the preparation of appropriate meals for infants and children Recurrent illness from respiratory and alimentary tract disorders and middle-ear inflammations Low family income, shortage and limited variety of food products at the household level Low birthweight Children of low income family (less than 10 thousand tugrigs per family member) are 3 times more susceptible to protein energy malnutrition Percentage of underweight children Relation between prevalence of malnutrition and household income 15 12 9 6 3 0 <10.000 10.000-30.000 >30.000 Family income per family member per month (by tugrugs) 9 out of 10 underweight children in poor families by live in rural area Percentage of underweight children in poor families, by residence Sums 41% Aimag center 48% City 11% Policy implications and recommendations Improve early childhood care (ECC) practices and child feeding at household and community level Change behavior of mothers by providing information on appropriate diet, develop a training curriculum on ECC & support system Organize systematic training and awareness increase for health workers, young mothers and women on early childhood care practices. Encourage community participation and social mobilization Cooperate with the National Poverty Alleviation Program for improvement of the nutrition status of poor mothers and children Establish a local fund for improvement of the nutrition status of pregnant and lactating women, and children living in poor conditions Support public and private companies in establishing a child feeding unit and food sanatoriums in local areas Support initiatives for mother and child friendly environment among the community and organizations. Upgrade nutrition information and improve monitoring activities Strengthen Child Growth Promotion system and establish a national database on child nutrition Improve evaluation, monitoring and supplementation of micronutrients to young children, lactating women, adolescent girls and of iron to pregnant women. Create a favorable legal and trade environment and improve collaboration and cooperation Improve collaboration among the Government, NGOs, public and international organizations in the activities to improve the nutrition status of mothers and children Vitamin D Deficiency Rickets reduction rate very slow in Mongolia Prevalence of Vitamin D deficiency, 1992-2000 50 44.7 40 37.7 30 32.1 20 10 0 1992 1997 1999 Rickets affects one in every four children under 1 in Mongolia Prevalence of rickets among children under 1 and under 5 50 40 30 20 10 0 City Aimag center Children under 5 Progress Sum Children under 1 Causes of rickets are : § irregular preventive activities from vitamin D deficiency for pregnant women and young children § insufficient child feeding practice of mothers § poor knowledge, practice of mothers on early childhood care Where rickets in children is highest Prevalence of rickets in children under 5 years of age Õîâä Prevalence of rickets has not decreased from the previous years’ rate. Compared to statistics for 1992, there is a decline of moderate and severe forms of rickets. ... but There is a higher prevalence in urban areas with more symptoms of severe rickets. In Mongolia, one in every four children under 1 is affected by rickets. Thirty two percent of children aged 0-5 have complex symptoms of rickets. 22.3 Äóíäãîâü Issue 24.4 Áàÿí-ªëãèé Deficiency of Vitamin D and other vitamins are associated child morbidity and mortality and also cause developmental delays in children under five. Therefore the situation demonstrates the need to intensify rickets prevention measures starting from child birth, particularly with regard to improving food supply of mothers and children in rural areas, to conducting education activities, and setting up and organizing a Vitamin D supplementation, monitoring and evaluation system. 26.3 ªìíºãîâü 27.7 Áàÿíõîíãîð 28.4 Ãîâü-Àëòàé 29.2 ¯íäýñíèé ò¿âøèí 32.1 Äîðíîä 39.3 Óëààíáààòàð 40.5 Àðõàíãàé Goal 53 Çàâõàí Reduction vitamin D deficiency among children under five by 5% of the 2000 level by the year 2006. 57.2 Ñýëýíãý 58.6 0 10 20 30 40 50 60 Source of all graphics:2nd National Nutrition survey, 2000, NRC and UNICEF Policy implications and recommendations Poor feeding practice is the underlying cause of micronutrient malnutrition Patterns of first complementary feeding and feeding practice of malnourished children 4-12 months: - Complementary feeding started by family meal - Weaning food - Food not being prepared specifically for the children - Bottle feeding - Complementary feeding started by bantan - Late start of complementary feeding 23.5% 11.1% 10.8% 7.1% 6.8% 6.7% A special policy to improve the food supply of vulnerable groups of the population needs to be implemented within the social safety system Successful implementation involves the participation and close collaboration of government leaders, local administration, NGOs, and all members of the society Create and streamline the legal environment for promoting fortified food production, supply and service Develop standards and technical conditions for food fortification Introduce modern technology for producing wheat flour fortified with vitamin D and iron Fortification and/or developing of dishes using animal blood should be investigated and tested Dietary energy supply for poor families Improve supply of essential supplements A regular supplement of iron, folic acid and vitamin D should be provided for children and women Vitamin A supplement should be provided, considering the high incidence of acute respiratory tract diseases in children Kcal per capita per day 2500 2000 1500 1000 500 0 1993-1996 1998 2000 Daily calorie intake in the food consumed by a household in urban and rural areas Daily calorie intake by level of subsistence living standard (SLS) Urban Daily calorie intake (kcal) 4000 Rural 3000 Recommended daily calorie intake 2000 1000 69% 58% 0 Higher than SLS At SLS Lower than SLS Household living condition by level of subsistence living standard (SLS) Sources of all graphics: Statistical Yearbook, 2000 and 2nd National Nutrition survey, 1999 Strengthen nutrition information and improve monitoring activities Develop and implement a methodology on prevention and monitoring vitamin D deficiency and iron deficiency anemia among children and pregnant and lactating women Improvement of evaluation, monitoring and research activities and supplementation of vitamin A, D and iron to young children, pregnant and lactating women and adolescent girls Develop IEC materials for health workers and community The IEC campaign should be conducted in order to bring about changes in community behavior. Information on protein energy deficiency and IDD, which is targeted at policy makers, parents, and care takers should be delivered in a timely way, to ensure sustainable effect Assessing the target population’s perceptions, beliefs and practices regarding food supply and diet would be an extremely valuable method of acquiring essential information, which could help change people’s behavior. Low Birthweight Better data on birthweight is important Many infants in developing countries are not weighed at birth. Percentage of infants not weighed/ birthweight unknown Mongolia 5 East Asia/ Pacific 40 Developing countries 65 2200 babies with low birthweight are born a year in Mongolia & their health and development is in risk Percentage of Low birthweight less than 2.5 kg Progress 9 Mongolia East Asia and Pacific 100 per cent of newborns are weighed at birth. Low Birthweight rate reduced by 2% in the last decade. 8 Developing countries ... but 15 World 14 0 5 10 15 Aimag center has the highest number of Low Birthweight Infants Issues Percentage of low birthweight children by residency 7 National average 6 6.1 5 4 5.4 5.8 4.8 3 2 1 0 Capital city Aimag center Soum center Countryside The Western region shows the highest incidence of low birthweight, at over 8% Percentage of low birthweight Sources for all map and graphs: MICS-2, 2001 An estimated 2200 babies with low birthweight are born nationwide, and 25% of them in Western aimags and 35% in Ulaanbaatar. Approximately 48.2% of malnourished children under 5 were born with low birth weight. >8 7 6 5> Children with low birthweight are more susceptible to affect protein energy malnutrition and anemia compared to children with normal wiegh. Children of nearly 13% of mothers under 19 years old were born with low birthweight. Nearly 30% of malnourished children were born by mothers, with Low Body Index. Goal Reduction of the rate of low birth weight infants (less than 2.5 kg) by 3% of the 2000 level by the year 2010 Policy implications and recommendations Promoting control of fetus weight gain during pregnancy Multiple micronutrient and multivitamin supplementation during pregnancy Food supplementation for under nourished pregnant women Prevention of smoking and drinking in pregnancy Prevention & treatment of asymptomatic bacteria Interventions, which delay timing of the first pregnancy to later than 19 years of age Immunization Measles immunization coverage, 2000 Percentage of measles vaccination coverage, 1993 and 2000 Mongolia East Asia/Pacific Global 0 20 40 60 80 100 % Neonatal tetanus Neonatal tetanus was eliminated in Mongolia before 1990 and consitutes no public health problem. New Hepatitis B vaccination introduced successfully Since 1990, Mongolian children are immunized with a course of lowdose hepatitis B vaccine within 48 hours after birth and at 2 and 8 years of age. As a result, mortality due to hepatitis B among the risk group was reduced by 3 times by the year 2000, compared to the 1990s level. The vaccine, available at all aimag, soum and bagh level, was very successful in controlling endemic hepatitis B infection, where the virus is spread predominantly by horizontal transmission among infants and young children. Almost 90 out of 100 children under one fully immunised by six antigens Immunization coverage (under 1 year of age) in 1993, 1995 and 2001 Hepatitis B Progress Immunisation coverage in Mongolia is considered satisfactory achieving 92-94% immunisation coverage for one-year old infants by six types of antigens. The country has received “Polio Free Country” certificate from WHO in 2001. No new cases of diphtheria, which reappeared in 1994, have been reported. ... but In 2001, the number of reported measles cases increased by 10 times compared to 2000. Child mortality from complications of tuberculosis and congenital syphilis is increasing. This is directly related to the regularity and quality of antenatal care, the quality of the vaccination service and measles surveillance as well as women’s health education. Goal Measles Maintenance of a high level of immunization coverage against diphtheria, pertussis, tetanus, measles, tuberculosis and hepatitis B OPV3 DPT3 BCG 0 20 40 60 80 100 Policy implications and recommendations Immunization Law In 2000, the Government of Mongolia approved the Immunization Law. The Immunization Law plays a significant role in prevention of infectious diseases and encouraging people to be responsible for their own health. Reaching and providing immunization to children without access to immunization services Ensuring that financial sustainability of immunization becomes one of priorities Fertility and Family Planning Use of modern contraceptives is the lowest in Northern region Use of modern contraceptives by regions, in percent 80 60 40 20 0 Central Western Southern Eastern Northern Progress IUD the most common methods of contraception Percentage of women aged 15-49 who use contraceptive methods IUD 34% Calendar 9% Condom 4% Injection 6% Others 6% Don’t used 33% Pill 3% Source: MICS-2, 2000, UNICEF Social factors related to fertility Ê Education, age and marital status affect fertility: better Ê Ê educated women have lower fertility than the less educated. Fertility levels in urban areas are lower than in rural areas and fertility level is the highest in the Western region. Nearly 22% of husbands do not approve family planning methods. Maternal death is the highest in the Western region Maternal mortality rate per 1000 live births High Medium Low Sources of map and graphic:Survey of Maternal mortality in Mongolia, 2001 Fertility rate has significantly decreased during the 1990s. Total fertility rate is 3 children per woman. Around 67% of reproductive age women use contraceptives, and among these 74% reported that they use modern methods. More than half of women use contraceptives free of charge. ... but The number of adolescents giving birth has increased in the last ten years. Nine per cent of 15-19 years old girls gave birth and in the South region 26% of teenage girls have started childbearing. Two third of unwanted pregnancies were terminated by abortions. Goal Improve use of contraceptive methods and reduce the rate of abortions the level of 2000 by the year 2006 UNICEF contributions and supports UNICEF mandate is: To protect the rights of the child and improve their health and nutrition. In Mongolia, UNICEF works with the Government of Mongolia, other UN agencies, non-governmental organizations, communities, families and children themselves. UNICEF supported six national programs in 1997-2000: 1. National Immunization Program, 1993-2001 2. National programs for controlling Acute Respiratory Infection and Control of Diarrheal Diseases, 1993-1999 3. National Program against Iodine Deficiency Disorder, 1996-1998 4. National Program on Children’s Development until 2000, 1997-2000 5. National Program on Nutrition and Health, 1997-2000 6. Health education program, 1998-2001 UNICEF will support four national programs related to health and nutrition in 2002-2006 within the new country program of cooperation: 1. National Immunization Program, 2002-2007 2. National Plan of Action for Food Security, Safety and Nutrition, 2001-2006 3. National Program on Elimination Iodine Deficiency Disorder, 2002-2007 4. National Plan of Action for the Development and Protection of Children, 2002-2010 UNICEF Expenditure on Health and Nutrition projects (in percentages) 1992 Support to Maternal and Child Nutrition Project (in percentages) 2001 UNICEF 60% Safe Motherhood Expanded program for Immunization Child Health Child Nutrition Results of the following surveys conducted with UNICEF Mongolia support, have been used for these Fact sheets: - Ministry of Health and UNICEF (2000), Survey on Mortality in Children under five: Causes and Influencing Factors. Ulaanbaatar - UNICEF (2000) Children and Women in Mongolia Situation Analysis Report-2000 (SITAN). Ulaanbaatar - Nutrition Research Center and UNICEF (2000) Second National Nutrition Survey. Ulaanbaatar - National Statistics Office and UNICEF (2001) Multiple Indicator Cluster Survey-2000 (MICS-2). Ulaanbaatar - Maternal Child Research Center, MOH and UNICEF (2001) Maternal Mortality in Mongolia 1996-1998. Ulaanbaatar - UNICEF (2001) Progress Since the World Summit for Children. New York - Nutrition Research Center and UNICEF (2001) Care practices for young children in Mongolia. Ulaanbaatar International NGOs 31% Government 9% For further information, please contact: Health and Nutrition project, UNICEF 210646 Negdsen Undestnii Street Ulaanbaatar-46, Mongolia E-mail: unicef@magicnet.mn Tel: 312183, 312185 and 312217 Fax: (976-11) 327313 Nutrition Research Center, PHI E-mail: NRC@magicnet.mn Tel: 455600 Fax: (976-11) 458645 Prepared by Dr. Oyunbileg. Sh. Local Consultant, UNICEF