EVERY MONGOLIAN CHILD HAS THE RIGHT ÒO HEALTHY GROWTH

ÞÍÈÑÅÔ IECD project, Health and Nutrition, UNICEF EVERY MONGOLIAN CHILD HAS THE RIGHT ÒO HEALTHY GROWTH FACTS AND FIGURES Inside: 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 Ulaanbaatar 22

Rural children have limited access to ARI care Percentage of children with ARI taken to health provider, by residence Mongolia East Asia and Pacific Developing countries Rural Urban 2 4 6 8 About 686 children aged -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, 2, by region 75 6 45 3 15 37.7 53.9 59.3 63.3 68.9 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. Integrated Management of Childhood Illnesses 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 Policy Implications and Recommendations 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

35 19 65 Percentage of under-fives underweight, 2 12 34 2 36 3 11 13 27 36 14 17 36 24 33 18 36 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 1 thousand tugrigs per family member) are 3 times more susceptible to protein energy malnutrition Relation between prevalence of malnutrition and household income Percentage of underweight children 15 12 9 6 3 <1. 1.-3. >3. Family income per family member per month (by tugrugs) 9 out of 1 underweight children in poor families by live in rural area Percentage of underweight children in poor families, by residence Sums 41% 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 Aimag center 48% City 11%

Vitamin D Deficiency Rickets reduction rate very slow in Mongolia Prevalence of Vitamin D deficiency, 1992-2 5 4 3 44.7 37.7 32.1 2 1 1992 1997 1999 Rickets affects one in every four children under 1 in Mongolia Prevalence of rickets among children under 1 and under 5 5 4 3 2 1 Where rickets in children is highest Prevalence of rickets in children under 5 years of age Õîâä Äóíäãîâü Áàÿí-ªëãèé ªìíºãîâü Áàÿíõîíãîð Ãîâü-Àëòàé íäýñíèé ò âøèí Äîðíîä Óëààíáààòàð Àðõàíãàé Çàâõàí Ñýëýíãý City Aimag center Sum Children under 5 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 22.3 24.4 26.3 27.7 28.4 29.2 32.1 39.3 4.5 53 57.2 58.6 Progress 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 -5 have complex symptoms of rickets. Issue 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. Goal Reduction vitamin D deficiency among children under five by 5% of the 2 level by the year 26. 1 2 3 4 5 6 Source of all graphics:2nd National Nutrition survey, 2, NRC and UNICEF

Daily calorie intake (kcal) 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 23.5% - Weaning food 11.1% - Food not being prepared specifically for the children 1.8% - Bottle feeding 7.1% - Complementary feeding started by bantan 6.8% - Late start of complementary feeding 6.7% Dietary energy supply for poor families Kcal per capita per day 25 2 15 1 5 1993-1996 1998 2 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) 4 3 2 1 Higher than SLS At SLS 69% 58% Lower than SLS Household living condition by level of subsistence living standard (SLS) Urban Rural Recommended daily calorie intake Sources of all graphics: Statistical Yearbook, 2 and 2 nd National Nutrition survey, 1999 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 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 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 4 Developing countries 65 22 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 Aimag center has the highest number of Low Birthweight Infants Percentage of low birthweight children by residency 7 6 5 4 3 2 1 Mongolia East Asia and Pacific Developing countries World 4.8 Capital city 6.1 Aimag center The Western region shows the highest incidence of low birthweight, at over 8% 5.4 Sources for all map and graphs: MICS-2, 21 8 9 14 15 5 1 15 5.8 Soum center Countryside National average Percentage of low birthweight >8 7 6 5> Progress 1 per cent of newborns are weighed at birth. Low Birthweight rate reduced by 2% in the last decade.... but An estimated 22 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. Issues 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 3% 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 2 level by the year 21 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, 2 Percentage of measles vaccination coverage, 1993 and 2 Mongolia East Asia/Pacific Global 2 4 6 8 1 % Neonatal tetanus Neonatal tetanus was eliminated in Mongolia before 199 and consitutes no public health problem. New Hepatitis B vaccination introduced successfully Since 199, 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 2, compared to the 199s 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 9 out of 1 children under one fully immunised by six antigens Immunization coverage (under 1 year of age) in 1993, 1995 and 21 Hepatitis B Measles OPV3 DPT3 BCG 2 4 6 8 1 Immunization Law In 2, 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. 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 21. No new cases of diphtheria, which reappeared in 1994, have been reported.... but In 21, the number of reported measles cases increased by 1 times compared to 2. 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 Maintenance of a high level of immunization coverage against diphtheria, pertussis, tetanus, measles, tuberculosis and hepatitis B Policy implications and recommendations 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 8 6 4 2 Central Western Southern Eastern Northern IUD the most common methods of contraception Percentage of women aged 15-49 who use contraceptive methods Condom 4% Injection 6% IUD 34% Pill 3% Calendar 9% Don t used 33% Others 6% Source: MICS-2, 2, UNICEF Social factors related to fertility Education, age and marital status affect fertility: better 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. Progress Fertility rate has significantly decreased during the 199s. 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 2 by the year 26 Maternal death is the highest in the Western region Maternal mortality rate per 1 live births High Medium Low Sources of map and graphic:survey of Maternal mortality in Mongolia, 21

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 1997-2: 1. National Immunization Program, 1993-21 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 2, 1997-2 5. National Program on Nutrition and Health, 1997-2 6. Health education program, 1998-21 UNICEF will support four national programs related to health and nutrition in 22-26 within the new country program of cooperation: 1. National Immunization Program, 22-27 2. National Plan of Action for Food Security, Safety and Nutrition, 21-26 3. National Program on Elimination Iodine Deficiency Disorder, 22-27 4. National Plan of Action for the Development and Protection of Children, 22-21 UNICEF Expenditure on Health and Nutrition projects (in percentages) Support to Maternal and Child Nutrition Project (in percentages) 1992 21 Safe Motherhood UNICEF 6% Expanded program for Immunization Child Health Child Nutrition International NGOs 31% Government 9% Results of the following surveys conducted with UNICEF Mongolia support, have been used for these Fact sheets: - Ministry of Health and UNICEF (2), Survey on Mortality in Children under five: Causes and Influencing Factors. Ulaanbaatar - UNICEF (2) Children and Women in Mongolia Situation Analysis Report-2 (SITAN). Ulaanbaatar - Nutrition Research Center and UNICEF (2) Second National Nutrition Survey. Ulaanbaatar - National Statistics Office and UNICEF (21) Multiple Indicator Cluster Survey-2 (MICS-2). Ulaanbaatar - Maternal Child Research Center, MOH and UNICEF (21) Maternal Mortality in Mongolia 1996-1998. Ulaanbaatar - UNICEF (21) Progress Since the World Summit for Children. New York - Nutrition Research Center and UNICEF (21) Care practices for young children in Mongolia. Ulaanbaatar For further information, please contact: Health and Nutrition project, UNICEF 21646 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: 4556 Fax: (976-11) 458645 Prepared by Dr. Oyunbileg. Sh. Local Consultant, UNICEF