What are the current states of indicators contributing to a comprehensive view of nutrition for health and development in Turkmenistan? Choose your country below and find selected national data on this NLiS country profile.
The Global Nutrition Monitoring Framework profile for Turkmenistan is now available at http://apps.who.int/nutrition/landscape/global-monitoring-framework?ISO=TKM
What does this indicator tell us?
At a population level, the proportion of infants with a low birth weight is an indicator of a multifaceted public health problem that includes long-term maternal malnutrition, ill-health and poor health care in pregnancy.
Low birth weight is included as a primary outcome indicator in the core set of indicators for the Global nutrition monitoring framework. It is also included in the WHO Global reference list of 100 core health indicators.
How is this indicator defined?
Low birth weight has been defined by WHO as weight at birth of <2500 g (5.5 pounds).
What are the consequences and implications?
Low birth weight is caused by intrauterine growth restriction, prematurity or both. It contributes to a range of poor health outcomes; for example, it is closely associated with fetal and neonatal mortality and morbidity, inhibited growth and cognitive development, and noncommunicable diseases (NCDs) later in life. Low birth weight infants are about 20 times more likely to die than heavier infants.
Low birth weight is more common in developing than developed countries. However, data on low birth weight in developing countries is often limited because a significant portion of deliveries occur in homes or small health facilities, where cases of infants with low birth weight often go unreported. These cases are not reflected in official figures and may lead to a significant underestimation of the prevalence of low birth weight.
Source of data
UNICEF data: monitoring the situation of children and women (https://data.unicef.org/).
Further reading
UNICEF-WHO Low birthweight estimates: Levels and trends 2000–2015. Geneva: World Health Organization; 2019 (https://www.who.int/nutrition/publications/UNICEF-WHOlowbirthweight-estimates-2019/en/).
WHO. Global nutrition targets 2025: low birth weight policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_lbw/en/).
WHO, UNICEF. Global nutrition monitoring framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/).
WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://www.who.int/healthinfo/indicators/2018/en/).
Internet resources
WHO. Feto-maternal nutrition and low birth weight. (http://www.who.int/nutrition/topics/feto_maternal/en/index.html).
WHO. Global targets 2025 to improve maternal, infant and young child nutrition (http://who.int/nutrition/global-target-2025/en/).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. (http://www.who.int/elena/global-targets/en).
Target 3: 30% reduction in low birth weight (http://www.who.int/elena/global-targets/en/#lowbirthweight).
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This indicator reflects the percentage of school-age children and adolescents aged 5–19 years who are classified as overweight, based on age- and sex-specific values for body mass index (BMI). Overweight indicates excess body weight for a given height from fat, muscle, bone, water or a combination of these factors, whereas obesity is defined as having excess body fat.
Overweight in school-age children and adolescents aged 5–19 years is included as an intermediate outcome indicator in the core set of indicators for the Global nutrition monitoring framework. It is also included in the NCD global monitoring framework, and in the WHO Global reference list of 100 core health indicators.
Prevalence of overweight in school-age children and adolescents is defined as the percentage of children aged 5–19 years with sex-specific BMI-for-age >+1 SD above the WHO 2007 reference median.
The immediate consequences of overweight and obesity in school-age children and adolescents include a greater risk of asthma and cognitive impairment, in addition to the social and economic consequences for the child, for the child’s family and for society. In the long term, overweight and obesity in children increase the risk of health problems later in life, including obesity, diabetes, heart disease, some cancers, respiratory disease, mental health and reproductive disorders. Furthermore, obesity and overweight track over the life-course – an overweight adolescent girl is more likely to become an overweight woman; thus, her baby is likely to have a heavier birth weight.
WHO. Global Health Observatory (GHO) data repository. Prevalence of overweight among children and adolescents, BMI > +1 standard deviations above the median, crude. (crude estimate) (%) (Noncommunicable diseases). Estimates by country, among children aged 5-19 years (http://apps.who.int/gho/data/view.main.BMIPLUS1C05-19v).
NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies with 128.9 million participants. Lancet. 2017;Dec 16;390(10113):2627–2642. doi:http://dx.doi.org/10.1016/S0140-6736(17)32129-3.
WHO. BMI-for-age (5–19 years). Growth reference 5–19 years. (http://www.who.int/growthref/who2007_bmi_for_age/en/).
WHO. NCD global monitoring framework. (http://www.who.int/nmh/global_monitoring_framework/en/).
WHO. Overweight and obesity. Fact sheet (http://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight).
WHO. Commission on ending childhood obesity (http://www.who.int/end-childhood-obesity/en/).
Target 7: Halt the rise in diabetes and obesity (http://www.who.int/elena/global-targets/en/#diabetesobesity).
The indicator anaemia has a wide variety of causes. Iron deficiency is considered to be the most common cause of anaemia; other causes include acute and chronic infections that result in inflammation and blood loss; deficiencies of other vitamins and minerals, especially folate, vitamin B12 and vitamin A; and genetically inherited traits, such as thalassaemia. Other conditions (e.g. malaria and other infections, genetic disorders, and cancer) can also play a role in anaemia. The terms “iron-deficiency anaemia” and “anaemia” are often used synonymously; also, the prevalence of anaemia has often been used as a proxy for iron-deficiency anaemia, although the degree of overlap between the two varies considerably from one population to another, according to gender and age.
Anaemia prevalence among pregnant and non-pregnant women are included as primary outcome indicators in the core set of indicators for the Global nutrition monitoring framework. These indicators are used to monitor progress towards achieving Global Nutrition Target 2, which is a 50% reduction in anaemia among women of reproductive age by 2025. Anaemia in women of reproductive age and in children are also included in the WHO Global reference list of 100 core health indicators.
Anaemia is defined as a haemoglobin concentration below a specified cut-off point; that cut-off point depends on the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives. WHO defines anaemia in children aged under 5 years and pregnant women as a haemoglobin concentration <110 g/L at sea level, and anaemia in non-pregnant women as a haemoglobin concentration <120 g/L.
Tests to measure haemoglobin levels are easy to administer. A few drops of blood obtained by a finger-stick can be used to assess haemoglobin concentrations in the field using a portable haemoglobinometer. The test could be easily integrated into regular health or prenatal visits or household surveys, to capture women of reproductive age, although the cost of the equipment and regular calibration needs to be taken into account.
Anaemia is associated with increased risks for maternal and child mortality. Iron-deficiency anaemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anaemia on the cognitive and physical development of children and on physical performance – particularly the work productivity of adults – are major concerns. Anaemia is a global problem affecting all countries. Resource-poor areas are often more heavily affected because of the prevalence of infectious diseases. Malaria, HIV/AIDS, hookworm infestation, schistosomiasis and other infections such as tuberculosis contribute to the high prevalence of anaemia in some areas.
The main risk factors for iron-deficiency anaemia include a low dietary intake of iron or poor absorption of iron from diets rich in phytates or phenolic compounds. Population groups with greater iron requirements, such as growing children and pregnant women, are particularly at risk. Overall, the most vulnerable, poorest and least educated groups are disproportionately affected by iron-deficiency anaemia.
Cut-off values for public health significance
Indicator
Prevalence cut-off values for public health significance
Anaemia
<5%: no public health problem
5–19%: mild public health problem
20–39%: moderate public health problem
≥40%:severe public health problem
Source: WHO (2008).
Sources of data
WHO. Global Health Observatory (GHO) data repository.
Prevalence of anaemia in pregnant women. Estimates by country. (http://apps.who.int/gho/data/view.main.ANAEMIAWOMENPWv).
Prevalence of anaemia in non-pregnant women. Estimates by country (http://apps.who.int/gho/data/view.main.ANAEMIAWOMENNPWv).
Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative data. Lancet Global Health. 2013;1:e16–25.
WHO. Global nutrition targets 2025: anaemia policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/).
WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. WHO/NMH/NHD/MNM/11.1. Geneva: World Health Organization; 2011 (http://www.who.int/vmnis/indicators/haemoglobin.pdf).
WHO. Vitamin and Mineral Nutrition Information System (VMNIS). (http://www.who.int/vmnis/en/).
WHO. Anaemia/iron deficiency list of publications. (http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/en/index.html).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Health conditions. Anaemia (http://www.who.int/elena/health_condition/en/#anaemia).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target (http://www.who.int/elena/global-targets/en):
Target 2: 50% reduction of anaemia in women of reproductive age (http://www.who.int/elena/global-targets/en/#anaemia).
Vitamin A deficiency results from a dietary intake of vitamin A that is inadequate to satisfy physiological needs. It may be exacerbated by high rates of infection, especially diarrhoea and measles. It is common in developing countries, but rarely seen in developed countries. Vitamin A deficiency is a public health problem in more than half of all countries, especially those in Africa and South-East Asia. The most severe effects of this deficiency are seen in young children and pregnant women in low-income countries.
Vitamin A deficiency can be defined clinically or subclinically. Xerophthalmia is the clinical spectrum of ocular manifestations of vitamin A deficiency; these range from the milder stages of night blindness and Bitot spots to the potentially blinding stages of corneal xerosis, ulceration and necrosis (keratomalacia). The various stages of xerophthalmia are regarded both as disorders and clinical indicators of vitamin A deficiency. Night blindness (in which it is difficult or impossible to see in relatively low light) is one of the clinical signs of vitamin A deficiency, and is common during pregnancy in developing countries. Retinol is the main circulating form of vitamin A in blood and plasma. Serum retinol levels reflect liver vitamin A stores when they are severely depleted or extremely high; however, between these extremes, plasma or serum retinol is homeostatically controlled and hence may not correlate well with vitamin A intake. Therefore, serum retinol is best used for the assessment of subclinical vitamin A deficiency in a population (not in an individual). Blood concentrations of retinol in plasma or serum are used to assess subclinical vitamin A deficiency. A plasma or serum retinol concentration <0.70 μmol/L indicates subclinical vitamin A deficiency in children and adults, and a concentration of <0.35 µmol/L indicates severe vitamin A deficiency.
Night blindness is one of the first signs of vitamin A deficiency. In its more severe forms, vitamin A deficiency contributes to blindness by making the cornea very dry, thus damaging the retina and cornea. An estimated 250 000–500 000 children who are vitamin A-deficient become blind every year, and half of them die within 12 months of losing their sight. Deficiency of vitamin A is associated with significant morbidity and mortality from common childhood infections, and is the world’s leading preventable cause of childhood blindness. Vitamin A deficiency also contributes to maternal mortality and other poor outcomes of pregnancy and lactation. It also diminishes the ability to fight infections. Even mild, subclinical deficiency can be a problem, because it may increase children’s risk for respiratory and diarrhoeal infections, decrease growth rates, slow bone development and decrease the likelihood of survival from serious illness.
Serum or plasma retinol
<0.70 μmol/L in preschool-age children
<2%: no public health problem
2–9%: mild public health problem
10–19%: moderate public health problem
≥20%: severe public health problem
Night blindness (XN) in pregnant women
≥5%: moderate public health problem
Source: WHO (2009).
WHO. Vitamin and Mineral Nutrition Information System (VMNIS). Micronutrients database. (http://www.who.int/vmnis/database/en/).
Stevens GA, Bennett JE, Hennocq Q, Lu Y, De-Regil LM, Rogers L et al. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. Lancet Glob Health. 2015;3:e528–36. doi:10.1016/S2214-109X(15)00039-X.
WHO. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO global database on vitamin A deficiency. Geneva: World Health Organization; 2009 (http://whqlibdoc.who.int/publications/2009/9789241598019_eng.pdf).
WHO. Serum retinol concentrations for determining the prevalence of vitamin A deficiency in populations. WHO/NMH/NHD/MNM/11.3. Geneva: World Health Organization; 2011 (http://www.who.int/vmnis/indicators/retinol.pdf).
WHO. Xerophthalmia and night blindness for the assessment of clinical vitamin A deficiency in individuals and populations. WHO/NMH/NHD/EPG/14.4. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/bitstream/10665/133705/1/WHO_NMH_NHD_EPG_14.4_eng.pdf).
WHO. Vitamin A deficiency list of publications. (http://www.who.int/nutrition/publications/micronutrients/vitamin_a_deficiency/en/).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Nutrients. Vitamin A. (http://www.who.int/elena/nutrient/en/#vitamina).
This indicator allows an assessment of iodine deficiency at the population level. Iodine is an essential trace element that is present in the thyroid hormones, thyroxine and triiodotyronine. It occurs most frequently in areas where there is little iodine in the diet – typically, these are remote inland areas where no marine foods are eaten. Urinary iodine concentration in children aged 6–12 years is included as an additional indicator in the WHO Global reference list of 100 core health indicators.
Although goitre assessment by palpation or ultrasound may be useful for assessing thyroid function, results are difficult to interpret once salt iodization programmes have started. The median urinary iodine concentration is considered to be the main indicator of iodine status for all age groups, because its measurement is relatively noninvasive, cost-efficient and easy to perform. Since most of the iodine absorbed by the body is excreted in the urine, it is considered to be a sensitive marker of current iodine intake and can reflect recent changes in iodine status. Median urinary iodine concentrations have been most commonly measured in school children aged 6–12 years, because it is easy to access this population.
For school-age children (≥6 years of age), an adequate iodine level is defined as a population median urinary iodine concentration of 100–199 μg/L, whereas a population median of <100 μg/L indicates that the population’s iodine intake is insufficient. When the population median is <20 μg/L, the population is described as having severe iodine deficiency; at 20–49 μg/L, it is described as having moderate iodine deficiency; and at 50–99 μg/L, it is described as having mild iodine deficiency. A population of school-age children should have a median urinary iodine concentration of at least 100 μg/L, with less than 20% of values being <50 μg/L. For pregnant women, the median urinary iodine should be between 150 µg/L and 249 μg/L.
Iodine-deficiency disorders, which can start before birth, jeopardize children’s mental health and often their very survival. During the neonatal period, childhood and adolescence, iodine-deficiency disorders can lead to hypothyroidism and hyperthyroidism. Serious iodine deficiency during pregnancy can result in stillbirth, spontaneous abortion and congenital abnormalities such as cretinism – a grave, irreversible form of mental retardation that affects people living in iodine-deficient areas of Africa and Asia. Of even greater significance is the less visible, yet pervasive, mental impairment that reduces intellectual capacity at home, in school and at work.
Cut-off values for public health significance in different target groups
Concentration cut-off values for public health significance
Iodine deficiency measured by median urinary iodine concentration (μg/L) in school-age children (≥6 years)a
Concentration
Iodine intake
Iodine status
<20 μg/L
Insufficient
Severe deficiency
20–49 μg/L
Moderate deficiency
50–99 μg/L
Mild deficiency
100–199 μg/L
Adequate
Adequate iodine nutrition
200–299 μg/L
Above requirements
May pose a slight risk of more than adequate iodine intake in these populations
≥300 μg/L
Excessiveb
Risk of adverse health consequences (e.g. iodine-induced hyperthyroidism or autoimmune thyroid disease)
Iodine deficiency measured by median urinary iodine concentration (μg/L) in pregnant women
<150 μg/L
150–249 μg/L
250–499 μg/L
≥500 μg/L
Iodine deficiency measured by median urinary iodine concentration (μg/L) in lactating womenc and children aged <2 years
<100 μg/L
≥100 μg/L
a Applies to adults, but not to pregnant and lactating women.
b The term “excessive” means “in excess of the amount required to prevent and control iodine deficiency”.
c Although lactating women have the same requirement as pregnant women, the median urinary iodine concentration is lower because iodine is excreted in breast milk.
Source: WHO (2013).
WHO. Vitamin and Mineral Nutrition Information System (VMNIS). Micronutrients database (http://www.who.int/vmnis/database/en/).
WHO. Goitre as a determinant of the prevalence and severity of iodine-deficiency disorders in populations. WHO/NMH/NHD/MNM/14.5. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/bitstream/10665/133706/1/WHO_NMH_NHD_EPG_14.5_eng.pdf).
WHO. Urinary iodine concentrations for determining iodine status deficiency in populations. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization; 2013 (http://www.who.int/nutrition/vmnis/indicators/urinaryiodine).
Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2011 and trends over the past decade. J Nutr. 2012;142:744–750.
WHO. Vitamin and Mineral Nutrition Information System (VMNIS). Urinary iodine concentrations for determining iodine status deficiency in populations (http://www.who.int/vmnis/indicators/urinaryiodine/en/).
WHO. Iodine deficiency list of publications. (http://www.who.int/nutrition/publications/micronutrients/iodine_deficiency/en/).
The births attended by skilled health personnel indicator measures the health system’s ability to provide sufficient care during birth – a period of high risk of morbidity and mortality. In NLiS, it is used as a proxy for access to health services and maternal care. This indicator is also included in the WHO Global reference list of 100 core health indicators.
This indicator gives the percentage of live births attended by skilled health personnel in a given period. A skilled birth attendant is an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (i.e. uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of women and neonates for complications. Traditional birth attendants, whether trained or not, are excluded from the category of “skilled attendant at delivery”.
In developed countries and in many urban areas in developing countries, skilled care at delivery is usually provided in health facilities. Births do, however, take place in various other appropriate places, from homes to tertiary referral centres, depending on availability and need. WHO does not recommend a particular setting for giving birth. Home delivery may be appropriate for normal births, provided that the person attending the delivery is suitably trained and equipped, and that referral to a higher level of care is an option; however, this may lead to an overestimation of births attended by skilled personal, because infants delivered outside of a health facility may not have their birth method recorded.
All women should have access to skilled care during pregnancy and at delivery, to ensure the detection and management of complications. One woman dies needlessly of pregnancy-related causes every minute, representing more than half a million mothers lost each year, a figure that has improved little over recent decades. Another 8 million or more women experience lifelong health consequences from the complications of pregnancy. Every woman, rich or poor, has a 15% risk for complications around the time of delivery, but almost no maternal deaths occur in developed regions. The lack of progress in reducing maternal mortality in many countries often reflects the low value placed on the lives of women and their limited role in setting public priorities. The lives of many women in developing countries could be saved by reproductive health interventions that people in rich countries take for granted, such as the presence of skilled health personnel at delivery.
WHO. Global Health Observatory (GHO) data repository. Births attended by skilled health personnel. Data by country (http://apps.who.int/gho/data/view.main.GSWCAH02v).
WHO, International Confederation of Midwives (ICM), International Federation of Gynaecology and Obstetrics (FIGO). Making pregnancy safer: the critical role of the skilled attendant. Geneva: World Health Organization; 2004 (http://www.who.int/maternal_child_adolescent/documents/9241591692/en/).
What do these indicators tell us?
These indicators are the percentage of the population with access to improved sanitation facilities and access to an improved drinking-water source.
The two indicators – “proportion of population using safely managed sanitation services” and “proportion of population using safely managed drinking services” – are included as intermediate outcome indicators in the core set of indicators for the Global nutrition monitoring framework.
How are these indicators defined?
Improved drinking-water sources are defined as those that are likely to be protected from outside contamination, and from faecal matter in particular. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Unimproved water sources include unprotected wells, unprotected springs, surface water (e.g. river, dam or lake), vendor-provided water, bottled water (unless water for other uses is available from an improved source) and tanker truck–provided water. According to the WHO/UNICEF joint monitoring programme, basic drinking-water services are defined as drinking water from an improved source, provided that collection time is not more than 30 minutes for a roundtrip, including queuing. Basic sanitation services are defined as use of improved sanitation facilities that are not shared with other households. This is identical to the “improved but not shared” category used in previous reports.
Improved sanitation facilities are defined as those that hygienically separate human waste from human contact. Improved sanitation includes flush or pour-flush to piped sewer system, septic tank pit latrines, ventilated-improved pit latrines, or pit latrines with slab or composting toilets. Shared or public-use sanitation facilities are not considered to be improved. Also, flush or pour-flush to elsewhere, pit latrines without slabs or open pits, bucket latrines, hanging latrines or open defecation are not considered to be improved sanitation.
Access to safe drinking water and improved sanitation are fundamental needs and human rights that are vital for the dignity and health of all people. The health and economic benefits of a safe water supply to households and individuals (especially children) are well documented.
· Basic and safely managed drinking water services. Data by country. (http://apps.who.int/gho/data/node.main.WSHWATER?lang=en).
· Basic and safely managed sanitation services. Data by country. (http://apps.who.int/gho/data/node.main.WSHSANITATION?lang=en).
WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) (https://washdata.org).
WHO. Water sanitation hygiene (http://www.who.int/water_sanitation_health/en/).
Estimates of vaccination coverage of children aged 1 year are used to monitor vaccination services, to guide disease eradication and elimination programmes, and to indicate health system performance. Indicators for immunization coverage rate by vaccine for each vaccine in the national schedule are included in the WHO Global reference list of 100 core health indicators.
Measles vaccination coverage is defined as the percentage of children aged 1 year who have received at least one dose of measles-containing vaccine in a given year. In countries that recommend that the first dose be given to children over 12 months of age, the indicator is calculated as the proportion of children aged under 24 months receiving one dose of measles-containing vaccine.
Measles is a leading cause of vaccine-preventable childhood deaths, and unvaccinated populations are at risk of the disease. Measles is a significant infectious disease because it is highly contagious; thus, the number of nonimmune people who would suffer complications after an outbreak would quickly overwhelm available hospital resources. When vaccination rates fall, the number of nonimmune individuals in the community rises and, in turn, the risk of an outbreak of measles also rises. Vaccination is therefore critical to reducing child mortality rates.
WHO. Global Health Observatory (GHO) data repository. Measles-containing-vaccine first-dose (MCV1). Immunization coverage estimates by country (http://apps.who.int/gho/data/view.main.80100).
WHO. Immunization, vaccines and biologicals. Measles (http://www.who.int/topics/measles/en/).
This indicator reflects the percentage of women who consumed any iron-containing supplements during their current or previous pregnancy within the past 2 years. It provides information about the quality and coverage of perinatal medical services.
Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care, to reduce the risk of low birth weight, maternal anaemia and iron deficiency. It is suggested that the supplement contains 30–60 mg of iron, with the higher dose preferred in settings where anaemia in pregnant women is a severe public health problem (≥40%), along with 400 µg of folic acid. Daily supplementation throughout pregnancy, beginning as early as possible after conception, is recommended in all settings. Despite its proven efficacy and wide inclusion in antenatal care programmes, the use of iron and folic acid supplementation has been limited in programme settings. Possible reasons for this include a lack of compliance, concerns about the safety of the intervention among women with an adequate iron intake, and variable availability of the supplements at community level. Intermittent use of iron and folic acid supplements by non-anaemic women is a recommended alternative to prevent anaemia and improve gestational outcomes in areas where the prevalence of anaemia among pregnant women is lower than 20%. The suggested dose is 120 mg elemental iron and 2800 µg (2.8 mg) folic acid provided weekly throughout the pregnancy, beginning as early as possible after conception.
This indicator is included as a process indicator in the core set of indicators for the Global nutrition monitoring framework.
This indicator is defined as the proportion of women who consumed any iron-containing supplements during their current or previous pregnancy within the past 2 years. Data can be reported on any iron-containing supplement, including iron and folic acid tablets, multiple micronutrient tablets or powders, or iron-only tablets (which will vary, depending on the country policy).
Improving the intake of iron and folic acid by women of reproductive age could improve pregnancy outcomes, and improve maternal and infant health. Iron and folic acid supplementation is used to improve the iron and folate status of women before and during pregnancy, in communities where food-based strategies are not yet fully implemented or effective. Folic acid supplementation (with or without iron) provided before conception and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects.
Anaemia during pregnancy places women at risk for poor pregnancy outcomes, including maternal mortality; it also increases the risks for perinatal mortality, premature birth and low birth weight. Infants born to anaemic mothers have less than one half the normal iron reserves. Morbidity from infectious diseases is increased in iron-deficient populations, owing to the adverse effect of iron deficiency on the immune system. Iron deficiency is also associated with reduced work capacity and reduced neurocognitive development.
Demographic and health surveys (DHS) program STATcompiler (http://www.statcompiler.com/).
WHO. Developing and validating an iron and folic acid supplementation indicator for tracking progress towards global nutrition monitoring framework targets. Final report - June 2018. Geneva: World Health Organization; 2018 (https://www.who.int/nutrition/publications/ironfolic-indicator-GNMF/en/).
WHO. Weekly iron and folic acid supplementation as an anaemia-prevention strategy in women and adolescent girls. Lessons learnt from implementation of programmes among nonpregnant women of reproductive age. Geneva: World Health Organization; 2018 (https://www.who.int/nutrition/publications/micronutrients/WIFS-anaemia-prevention-womenadolescent-girls/en/).
WHO. Weekly iron-folic acid supplementation (WIFs) in women of reproductive age: its role in promoting optimal maternal and child health. Geneva: World Health Organization; 2009 (http://www.who.int/nutrition/publications/micronutrients/weekly_iron_folicacid.pdf).
WHO. Global targets 2025 to improve maternal, infant and young child nutrition. (http://who.int/nutrition/global-target-2025/en/).
WHO. e-Library of Evidence for Nutrition Actions (eLENA)
This indicator is the prevalence of children with diarrhoea who received oral rehydration solution (ORS). The percentage of children aged under 5 years with diarrhoea receiving ORS is an intermediate outcome indicator of the Global Nutrition Targets. Coverage of diarrhoea treatment is also included in the Global reference list of 100 core health indicators.
This indicator is the proportion of children aged 0–59 months who had diarrhoea in the previous 2 weeks and who received ORS (fluids made from ORS packets or pre-packaged ORS fluids). Diarrhoea is defined as the passage of three or more loose or liquid stools per day.
Diarrhoeal diseases remain one of the major causes of mortality among children aged under 5 years, accounting for 9% of deaths among children worldwide. Most of the deaths in children from diarrhoea could be averted by using ORS and zinc supplementation during episodes of diarrhoea, and basic interventions to improve drinking water, sanitation and hygiene (WASH). It is estimated that ORS alone can prevent 93% of deaths due to diarrhoea, and zinc supplementation can decrease deaths from diarrhoea by 23%.
WHO. Global Health Observatory (GHO) data repository. Preventing child deaths. Data by country (http://apps.who.int/gho/data/view.main.1600).
WHO. Diarrhoeal disease. Fact sheet. Geneva: World Health Organization; 2017 (http://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease).
This indicator reflects the prevalence of children who were given zinc as part of treatment for acute diarrhoea. There are no readily available data on this indicator, which is maintained in the NLiS to encourage countries to collect and compile data on these aspects, in order to assess their national capacity.
There is no internationally accepted indicator for zinc treatment of children with diarrhoea; however, this indicator could be defined as the percentage of children aged under 5 years with acute diarrhoea who were given supplements of 20 mg zinc daily for 10–14 days, or supplements of 10 mg/day for infants under 6 months.
One of the measures used to prevent childhood diarrhoeal episodes is the promotion of zinc intake. Diarrhoeal diseases account for nearly 2 million deaths a year among children aged under 5, making such diseases the second most common cause of child death worldwide. Zinc supplementation improves the outcomes of diarrhoeal treatment.
Protective and preventive measures against acute diarrhoea recommended by WHO and UNICEF are exclusive breastfeeding, adequate complementary feeding and continued breastfeeding, vitamin A supplementation, improved hygiene, better access to clean sources of drinking-water and sanitation facilities, and vaccination against rotavirus. Zinc supplementation, oral rehydration therapy and continued feeding are among the recommended safe and effective methods of treating diarrhoea. Specifically, zinc supplements given during an episode of acute diarrhoea reduce the duration and severity of the episode, and giving zinc supplements for 10–14 days lowers the incidence of diarrhoea in the following 2–3 months.
UNICEF data: monitoring the situation of children and women. Diarrhoeal disease (https://data.unicef.org/topic/child-health/diarrhoeal-disease/).
WHO, UNICEF. Ending preventable child deaths from pneumonia and diarrhoea by 2025. The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). Geneva: World Health Organization; 2013 (http://www.who.int/maternal_child_adolescent/documents/global_action_plan_pneumonia_diarrhoea/en/).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Zinc supplementation in the management of diarrhoea. (http://www.who.int/elena/titles/zinc_diarrhoea/en/).
What do these indicators tll us?
These indicators tell us what proportion of children aged 6–59 months received a dose of vitamin A through the main distribution mechanism during the first semester (January–June) and what proportion of children received a dose during the second semester (July–December). Vitamin A supplementation coverage is included in the WHO Global reference list of 100 core health indicators.
How are they defined?
These indicators are defined as the proportion of children aged 6–59 months who receive a first and/or a second high dose of vitamin A supplements within a calendar year. The two-dose coverage can be determined by the semester that achieved the lower vitamin A supplementation coverage for children aged 6–59 months in the calendar year.
Current international recommendations call for high-dose vitamin A supplementation every 4–6 months for all children between the ages of 6 and 59 months living in affected areas. The recommended doses are 100 000 international units (IU) for children aged between 6 and 11 months, and 200 000 IU for children aged between 12 and 59 months.
Programmes to control vitamin A deficiency increase children’s chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals, and contribute to the well-being of children, their families and communities.
Vitamin A is vital to child health and immune function; hence, in settings where vitamin A deficiency is a public health problem, vitamin A supplementation is recommended in infants and children aged 6–59 months as a public health intervention to reduce child morbidity and mortality. Measuring the proportion of children who have received two doses of vitamin A within the past year can be used to monitor coverage of interventions aimed at increasing child survival rates. Supplementation with vitamin A is a safe, cost-effective and efficient means for eliminating deficiency of this vitamin and improving child survival.
UNICEF data: monitoring the situation of children and women. Vitamin A deficiency (https://data.unicef.org/topic/nutrition/vitamin-a-deficiency/).
WHO. Immunization, vaccines and biologicals. Vitamin A supplementation (http://www.who.int/immunization/programmes_systems/interventions/vitamin_A/en/).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Vitamin A supplementation in infants and children 6–59 months of age. (http://www.who.int/elena/titles/vitamina_children/en/).
The Baby-friendly Hospital Initiative (BFHI), launched by WHO and UNICEF in 1991, is part of a global effort to protect, promote and support optimal breastfeeding practices. To be designated as “baby-friendly”, facilities must implement the Ten steps to successful breastfeeding to protect, promote and support breastfeeding. This indicator reflects the proportion of babies born in facilities that have been designated as baby-friendly.
The indicator “Proportion of births in baby-friendly facilities” is included as a process indicator in the core set of indicators for the Global nutrition monitoring framework.
This indicator is defined as the proportion of babies born in facilities designated as baby-friendly in a calendar year. To be counted as currently baby-friendly, the facility must have been designated within the past 5 years or have been reassessed within that time frame. Facilities may be designed as baby-friendly if they meet the minimum global criteria, which includes adherence to:
· the Ten steps for successful breastfeeding – these steps include having a breastfeeding policy that is routinely communicated to staff, having staff trained on policy implementation, informing pregnant women on the benefits and management of breastfeeding, and promoting early initiation of breastfeeding; and
· the International Code of Marketing of Breast-milk Substitutes – the Code restricts the distribution of free infant formula and promotional materials from infant formula companies.
Research has found that adherence to BFHI’s Ten steps leads to improved breastfeeding outcomes, which positively impact the health of both the mother and child. The more of the Ten steps that the mother experiences, the better her success with breastfeeding. Improved breastfeeding practices worldwide could save the lives of more than 800 000 children every year.
WHO. National implementation of the Baby-friendly Hospital Initiative 2017. Geneva: World Health Organization; 2017 (http://who.int/nutrition/publications/infantfeeding/bfhi-national-implementation2017/en/).
WHO, UNICEF. Global nutrition targets 2025: breastfeeding policy brief. Geneva: World Health Organization; 2014 (http://who.int/nutrition/publications/globaltargets2025_policybrief_breastfeeding/en/).
WHO. Baby-friendly Hospital Initiative. (http://www.who.int/nutrition/bfhi/en/).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Implementation of the Baby-friendly Hospital Initiative. (http://www.who.int/elena/titles/implementation_bfhi/en/).
Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process, with important implications for the health of mothers. Optimal practices include early initiation of breastfeeding within 1 hour and exclusive breastfeeding for 6 months, followed by appropriate complementary with continued breastfeeding for 2 years or beyond. Although it is a natural act, breastfeeding is also a learnt behaviour. Almost all mothers can breastfeed, provided they have accurate information and have support within their families and communities, and from the health care system. Mothers should also have access to skilled practical help from, for example, trained health workers, lay and peer counsellors, and certified lactation consultants. These professionals can help to build a mother’s confidence, improve feeding technique, and prevent or resolve breastfeeding problems.
This indicator has been established to measure the proportion of mothers receiving breastfeeding counselling, support or messages. The proportion of mothers of children aged 0–23 months who have received counselling, support or messages on optimal breastfeeding at least once in the previous 12 months is included as a process indicator in the core set of indicators for the Global nutrition monitoring framework.
This indicator gives the percentage of mothers of children aged 0–23 months who have received counselling, support or messages on optimal breastfeeding at least once in the past year.
WHO and UNICEF are in the process of further developing and validating this indicator. Meanwhile, an interim indicator has been established to measure the availability of all provision for breastfeeding counselling services in public health or nutrition programmes.
Counselling and informational support on optimal breastfeeding practices for mothers improves initiation and duration of breastfeeding, which has many health benefits for both the mother and infant. Breast milk contains all the nutrients an infant needs in the first 6 months of life. Also, breastfeeding protects against diarrhoea and common childhood illnesses such as pneumonia, and it may have longer term health benefits for the mother and child, such as reducing the risk of overweight and obesity in childhood and adolescence. Breastfeeding has also been associated with a higher intelligence quotient (IQ) in children. Improved breastfeeding practices worldwide could save the lives of more than 800 000 children every year.
TBD
WHO, UNICEF. Global strategy for infant and young child feeding. Geneva: World Health Organization; 2003 (http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/).
· Breastfeeding education for increased breastfeeding duration (http://www.who.int/elena/titles/breastfeeding_education/en/).
· Implementation of the Baby-friendly Hospital Initiative (http://www.who.int/elena/titles/implementation_bfhi/en/).
Salt iodization has been adopted as the main strategy to eliminate iodine-deficiency disorders as a public health problem; the aim is to achieve universal salt iodization. While other foodstuffs can be iodized, salt has the advantage of being both widely consumed and inexpensive. Salt has been iodized routinely in some industrialized countries since the 1920s. This indicator is a measure of whether a country’s fortification programme is reaching the target population adequately.
The indicator is a measure of the percentage of households consuming iodized salt, which is defined as salt containing 15–40 parts per million of iodine. Preferably, household access to iodized salt should be >90%.
Iodine deficiency is most commonly and visibly associated with thyroid problems (e.g. hyperthyroidism or hypothyroidism, goitre or an enlarged thyroid gland). However, it takes its greatest toll in impaired mental growth and development in children, which contribute to poor school performance, reduced intellectual ability and impaired work performance.
UNICEF data: monitoring the situation of children and women. Iodine deficiency (https://data.unicef.org/topic/nutrition/iodine-deficiency/).
WHO. Micronutrient deficiencies: iodine deficiency disorders. (http://www.who.int/nutrition/topics/idd/en/).
WHO. e-Library of Evidence for Nutrition Actions (eLENA). Iodization of salt for the prevention and control of iodine deficiency disorders. (http://www.who.int/elena/titles/salt_iodization/en/).
