This document profiles the state of nutrition in the Madhubani district of Bihar, India. It finds that child undernutrition levels are very high, with over 50% of children stunted and underweight. Anemia prevalence among children, pregnant women and adolescent girls is also alarmingly high. Infant and young child feeding practices are poor - very few infants are breastfed early or receive a diverse diet. Access to healthcare, sanitation and nutrition services is limited. High levels of poverty, food insecurity, illiteracy, and lack of access to water and electricity contribute to undernutrition in the district. The data shows that urgent action is needed across multiple sectors to address the complex causes of undernutrition in Madhubani.

1. 51.8
19.1
45.4
62.9
32.0
6.2
48.3
20.8
43.9
63.5
30.4
9.5
0.6
Children stunted
(<5 yr) (%)
Children wasted
(<5 yr) (%)
Children
underweight
(<5 yr) (%)
Children with any
anemia
(0-59 mo) (%)
Women
underweight (BMI
<18.5)
(15-49 yr) (%)
Children with
birthweight
<2500gms
(0-2 mo) (%)
Adults who are
obese in the
district
(18-59 yr) (%)
Madhubani Bihar
13.1% 0.1% 86.8%
3.6% 96.4%
51.9% 48.1%
Madhubani, Bihar
DISTRICT NUTRITION PROFILE
Page 1
THE STATE OF NUTRITION IN MADHUBANI3,4,5
DISTRICT DEMOGRAPHIC PROFILE1
Total Population 4,487,379
MALE FEMALE
RURALURBAN
SC ST OTHERS
CHANGES OVER TIME IN ANEMIA3,5,6,7
CHILDREN
STUNTED
CHILDREN
WASTED
CHILDREN
UNDERWEIGHT
51.8%
19.1%
45.4%
Madhubani ranks 520th
amongst 599 districts in India2
DISTRICT DEVELOPMENT INDEX (2015)
NFHS 4 (2015-2016)
100
62.6
62.9
97.6 78.0 80.7
63.5
DLHS 2 (2002-2004)^ NFHS 3 (2005-2006)^^ CAB (2014)^^ NFHS 4 (2015-2016)^^
Madhubani Bihar
NoData
CHHNS 7 (2015) CAB (2014)NFHS 4 (2015-2016)
PREVALENCE OF
ANEMIA AMONGST
CHILDREN UNDER-SIX
DECREASED IN THE
DISTRICT BETWEEN
2002 AND 2016
!
NFHS 4 (2015-2016)
NFHS 4 (2015-2016) NFHS 4 (2015-2016)
^Children aged 0-71 months
^^Children aged 0-59 months
NoData

2. 27.3
54.0
100.0
34.6
58.3
99.2
Women who received
ANC in the first
trimester
(15-49 yr) (%)
Anemia among
pregnant women
(15-49 yr) (%)
Anemia among
adolescent girls
(10-19 yr) (%)
Madhubani Bihar
32.6
63.2
23.8
8.7
48.9
61.2
9.7
46.0
1.9
34.9
53.5
30.7
7.3
61.7 62.3
10.4
45.2
2.5
Children breastfed
within one hour of
birth
(<3 yr) (%)
Children exclusively
breastfed
(0-6 mo) (%)
Children who
received any
solid/semi solid
food in the last 24
hours
(6-8 mo) (%)
Children who
achieve minimum
diet diversity
(6-23 mo) (%)
Children with full
immunization
coverage
(12-23 mo) (%)
Children who got
vitamin A
supplementation
(9-59 mo) (%)
Children suffering
from diarrhoea in
the last 2 weeks
(<5 yr) (%)
Children with
diarrhoea treated
with ORS
(<5 yr) (%)
Children showing
symptoms of ARI
(<5 yr) (%)
DISEASE BURDEN3
Page 2
Child undernutrition is caused by inadequacies in food, health and care for infants and young children, especially in
the first two years of life (immediate causes). Inadequate food, health and care arise from food insecurity, unsanitary
living conditions, low status of women, and poor health care (underlying causes). These are, in turn, caused by social
inequity, economic challenges, poor political will and leadership to address these causes (basic causes). Interventions
to address undernutrition must address these multiple causes of undernutrition and do so in an equitable manner.
IMMEDIATE CAUSES OF UNDERNUTRITION
Areas for action:
Data challenges:
IMMEDIATE CAUSES
Breastfeeding, nutrient rich foods, and eating routine
Feeding and caregiving practices, parenting stimulation
Low burden of infectious diseases
Optimum fetal and child nutrition and development
WHAT FACTORS CAUSE UNDERNUTRITION?13
UNDERLYING CAUSES
Food security: availability, economic access and use of food
Feeding and caregiving resources (maternal, household and
community level)
Access to and use of health services, a safe and hygienic environment
BASIC CAUSES
Knowledge and evidence
Politics and governance
Leadership, capacity and financial resources
Social, economic, political, and environmental context
(national and global)
The most crucial period for child nutrition is
from pre-pregnancy to the second year of life2
HOW CAN NUTRITION IMPROVE?
ADOLESCENT & MATERNAL HEALTH3,5
INFANT AND YOUNG CHILD FEEDING3
0
10
20
30
40
50
60
70
80
90
100
Age of child (in months)
Percentageofchildstunting(%)
Window of
opportunity
Too late
IMMUNIZATION &
SUPPLEMENTATION3
DLHS 2 (2002-2004)
• Poor state of infant and young child feeding: Very few infants
are breastfed within on hour of birth, and diet diversity rates are
poor
• Low rates of immunization, which needs urgent attention
• Few children with diarrhoea are treated with ORS
• Alarming levels of anaemia among adolescent girls
• Less than half of women in the district, report having received
ANC in the first trimester
• Where data are available, indicator definitions are non-
standardized and often differ from World Health
Organisation recommendations
NFHS 4 (2015-2016)
NFHS 4 (2015-2016)
NFHS 4 (2015-2016) NFHS 4 (2015-2016) NFHS 4 (2015-2016)
NFHS 4 (2015-2016)
NFHS 4 (2015-2016)NFHS 4 (2015-2016)NFHS 4 (2015-2016)
NFHS 4 (2015-2016)
NFHS 4 (2015-2016)

3. 48.0
97.9
27.3
38.0
50.4
91.7
57.2
44.4
Adult literacy rate (%) Households with access to primary/middle
school (%)
Households who demanded and received
work through NREGA (%)
Households availing banking services (%)
Madhubani Bihar
44.4
28.2
45.9
15.4
46.9 43.9
12.6
49.4
34.8
53.2
34.1
50.9 48.1
16.4
Household share of
expenditure on food
(%)
Household share of
food expenditure on
cereals (%)
Households in the
district involved in
agriculture (%)
Households Below
Poverty Line (%)
Household ownership
of agricultural land (%)
Households living in a
pucca house (%)
Household access to
electricity (%)
Madhubani Bihar
40.9
18.8
40.9
12.0
22.2
99.6
19.1
80.5
10.5
49.6
22.8
39.1
12.2
21.2
98.2
25.2
75.8 73.3
20.8
Women who are
literate
(15-49 yr) (%)
Women who
completed 10 or
more years of
schooling
(15-49 yr) (%)
Girls married
when <18 years
old
(20-24 yr) (%)
15-19 year old
women who are
mothers or
pregnant
(%)
Total unmet need
for family
planning
methods among
women
(15-49 yr) (%)
Households with
access to
improved
drinking water
sources (%)
Households with
access to
improved
sanitation
facilities (%)
Households
practicing open
defecation (%)
Households
disposing of child
stool in a sanitary
manner (%)
Households
washing hands
with soap before
meals (%)^
NFHS 3 (2005-2006)
Nodata
Census (2011)
SOCIO ECONOMIC CONDITIONS 1,9,14,15
Page 3
UNDERLYING CAUSES OF UNDERNUTRITION
BASIC CAUSES OF UNDERNUTRITION1,8,9
• Per capita gross district domestic product of Madhubani ranked 33rd amongst 38 districts of Bihar in 2011-1215
• Bihar’s per capita income ranked last amongst 32 major States/UTs in India in 2011-1216
• Action needs to be taken to improve adult literacy which is low
• No data available on indicators of governance and political will to address nutrition
Areas for immediate action:
• Very high rates of open defecation; critical need to increase awareness about washing hands with soap and ensuring
access to improved sanitation facilities
• Less than half of women in the district are literate
• Food insecurity, especially diet quality, is a challenge that can hold back improvements in nutrition
• Very few households live in a ‘pucca’ house and have access to electricity
Data challenges:
• Outdated data on open defecation
• No district-level data on child stool disposal
WOMEN’S STATUS3
WATER, SANITATION AND HYGIENE1,4,7
FOOD SECURITY 9
CHHNS 7 (2015)
Census (2011) Census (2011)NSS 68th round (2011-2012) NSS 68th round (2011-2012)
NSS 68th round (2011-2012)
Census (2011)Census (2011)
DLHS 3 (2007-2008)
NSS 68th round (2011-2012) NSS 68th round (2011-2012)NSS 68th round (2011-2012)
NFHS 4 (2015-2016)
NFHS 4 (2015-2016)
NFHS 4 (2015-2016)
NFHS 4 (2015-2016) NFHS 4 (2015-2016) NFHS 4 (2015-2016) NFHS 4 (2015-2016)

4. 75.3
5.2
81.3
91.7
47.9
3.2
63.8
8.2 9.4
86.8 91.7
32.7 31.0
Institutional deliveries
(Women 15-49 yr) (%)
Home births attended by
skilled health personnel
(Women 15-49 yr) (%)
New born received check up
within 24 hours of
birth/disharge (%)
Households (with 12-23 mo
child) with an
immunization/MCP card (%)
Households with access to
Anganwadi worker (%)
Households with access to a
Sub-Health Centre (%)
Households that received
financial assistance for
delivery and childcare (%)
27.6
63.2
40.3
21.7
43.9
Households that receive any
take home ration (%)
Women who received THR
during pregnancy (%)
Households with access to
PDS (%)
Madhubani Bihar
NoData
This District Nutrition Profile was developed by Abhilasha Vaid and Srabashi Ray for POSHAN. This version,
dated 06-05-2016 is a draft intended for use in a district-level workshop in Madhubani, and will be revised
following workshop discussions.
EVALUATION OF HEALTH AND NUTRITION SCHEMES3,4,8,9,12
FLW visits4
^2 recommended visits; *3 recommended visits
Last Trimester^ Within 1 week of delivery*
Within 24
hours of
delivery
Less than
recommended
Equal to
recommended
More than
recommended
Less than
recommended
Equal to
recommended
More than
recommended
Bihar 9,4% 9,4% 17,8% 29,1% 4,9% 5,2% 33,4%
Madhubani 6,8% 7,1% 13,2% 27,2% 4,1% 4,1% 28,5%
NSS 68th round (2011-2012)
DLHS 3 (2007-2008) DLHS 3 (2007-2008)
NFHS 4 (2015-2016)
CHHNS 7 (2015) RSOC (2013-2014)
NoData
CHHNS 7 (2015)CHHNS 7 (2015)
NFHS 4 (2015-2016)
Areas for immediate action:
• Access to skilled health personnel and Sub-Health Centres is
very limited
• Only 3.2% of households receive financial assistance for
delivery and child care
• Less than half of the eligible households receive any take home
ration
Data challenges:
• Lack of data on assessing the implementation of government
schemes
RSOC (2013-2014)
Data sources
1. Census of India. 2011. Primary Census Abstract. Accessed June 6, 2015, www.censusindia.gov.in/pca/default.aspx
Census of India. 2011. Houselisting and Housing Census Data. Accessed March 18, 2015, www.censusindia.gov.in/2011census/hlo/HLO_Tables.html
2. Us-India Policy Institute. 2015. District Development and Diversity Index. Accessed July 2, 2015, http://www.usindiapolicy.org/updates/general-news/225-district-development-and-diversity-index-
report
3. National Family Health Survey (NFHS-4), 2015-16, India. Mumbai: International Institute for Population Studies.
4. Concurrent Household Health and Nutrition Survey (Round-7), Concurrent Monitoring and Learning Unit, CARE India – Bihar
5. Census of India. 2014. Clinical, Anthropometric & Bio-chemical (CAB) survey. http://www.censusindia.gov.in/2011census/hh-series/HH-2/Bihar%20CAB%20Sample%20Characteristics%202014.pdf
6. Author’s estimates based on District Level Household Survey on Reproductive and Child Health (DLHS-2), 2002-04, India.
International Institute for Population Studies. (IIPS). 2006. District Level Household Survey on Reproductive and Child Health (DLHS-2), 2002-04, India: Nutritional Status of Children and Prevalence of
Anemia among Children, Adolescent Girls and Pregnant Women. Mumbai: IIPS. March 18, 2015, www.rchiips.org/pdf/rch2/National_Nutrition_Report_RCH-II.pdf
7. Author’s estimates based on National Family Health Survey (NFHS-3), 2005-06, India. Mumbai: International Institute for Population Studies.
8. International Institute for Population Studies (IIPS). 2010. District Level Household Survey and Facility Survey (DLHS-3), 2007-08, India, Bihar. Mumbai: IIPS. Accessed June 28, 2015,
http://rchiips.org/pdf/rch3/report/BH.pdf
9. Author’s estimates based on Household Consumption Expenditure, National Sample Survey Office (NSSO) 68th Round, 2011-12. Ministry of Statistics and Program Implementation. Government of
India
Author’s estimates based on Employment and Unemployment, National Sample Survey Office (NSSO) 68th Round, 2011-12. Ministry of Statistics and Program Implementation. Government of India
10. Finance Department, Government of Bihar. Economic Survey Report 2011-12: Gross District Domestic Product at Constant Prices (2005-06). Accessed March 18, 2015,
http://finance.bih.nic.in/Documents/Reports/Economic-Survey-2012-EN.pdf
11. Government of India. 2014. State-wise Per Capita Income and Gross Domestic Product at current prices. Accessed July 2, 2015, http://pib.nic.in/archieve/others/2014/aug/d2014070801.pdf
12. UNICEF. 2013-2014. Rapid Survey on Children (RSoC). http://wcd.nic.in/RSOC/21.RSOC_Bihar.pdf
13. Robert E Black, Cesar G Victora, Susan P Walker, Zulfiqar A Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, Sally Grantham-McGregor, Joanne Katz, Reynaldo Martorell, Ricardo Uauy, and
the Maternal and Child Nutrition Study Group. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries”. The Lancet 382 (9890), 427-451.
14. Planning Commission. 2013. Press note on poverty estimates, 2011-12. Government of India. Accessed March 18, 2015. http://planningcommission.nic.in/news/pre_pov2307.pdf
15. Government of Bihar. 2015. Economic Survey 2014-15. Accessed July 2,2015, http://finance.bih.nic.in/Documents/Reports/Economic-Survey-2015-EN.pdf
16. Government of India. 2014. State-wise Per Capita Income and Gross Domestic Product at current prices. Accessed July 2, 2015, http://pib.nic.in/archieve/others/2014/aug/d2014070801.pdf
17. Photo Credit: Stephan Rebernik. 2012. https://www.flickr.com/photos/stephanrebernik/7316902886/in/photolist-c9z3j3-84jAhD-dBqB49-bvwZKN-r9S16m-7hbFtw-ww5wR-k32J4Y-9EU6Yp-aMYGun-
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