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TABLE 3. Results of least-squares regression of nutrition measures as a function of morbidity and food availability (price)

a. Weight for age below -2 SD of the reference mean.

Thus, these results suggest that clinic-based anthropometric indicators are responsive both to changes in food availability and to morbidity levels with relatively short time-lags. However, several issues relevant to the use of such indicators for early/ timely warning systems remain unresolved. First, although they appear to be relatively sensitive to changes in food availability, are the anthropometric indicators more specific indicators of food stress than grain prices, which, as was argued above, may be influenced by factors unrelated to the onset of severe food stress situations and thus may lead to erroneous predictions of imminent famine situations (i.e. false positives)? Second, how is the sensitivity of the nutrition status indicators affected when the variability associated with morbidity is removed statistically?

In order to assess these issues, each month during the study period was coded as being either a famine month or a non-famine month, and regression models were fitted following the procedures described earlier. Table 4 presents the results of the analyses fitting the different measures of nutrition status to famine months. For both raw and deseasonalized squared mean Z scores, only the third preceding month's value was a significant predictor of a famine month, which would be expected when modelling a non-independent sequential series of observations, and the utility of that measure as a predictor was poor. There was no suitable cut-off point that discriminated famine from non-famine months with acceptable sensitivity and specificity.

The prevalence measure proved to be more highly correlated with the famine months, with the variance of the predicted values clearly greater than with Z scores and most of the high values associated with famine months. Specificity is improved by the model using deseasonalized prevalence (fig. 5), in which there is no substantial increase in predicted values during the earlier non-famine period.

We next removed the variance associated with morbidity by subtracting from each prevalence measure the values of earlier morbidity weighted by the coefficients given in table 3. The logistic model using these morbidity-adjusted values retains the high specificity noted in the simpler model while providing remarkable discrimination of the early famine period (fig. 6). Early and sharp discrimination of famine conditions during this period is an obvious and important determinant of the utility of any early warning indicator.

If the famine was under way by the summer of 1984, then perhaps the seasonal decrease in morbidity during that period masked its early effects on the

nutrition status of children in the clinics in the raw data series. Removing the effect of this decrease appears to result in better discrimination of early famine conditions in this population.

TABLE 4. Results of logistic regression using nutrition measures to predict famine

FIG. 5. Predicted probability of famine-deseasonalized proportion of weights below -2 SD

There are, unfortunately, limitations in interpreting these results. Despite the rather sharp discrimination shown in the logistic regressions, it is not possible to identify exact cutoff points for various interventions from this analysis because of the singularity of the famine and the relatively short period covered by the series. The data do indicate, however, that prevalence data from a clinic sample show promising utility as early/timely famine indicators.

Discussion

This study indicates that the application of time-series and multivariable techniques to routine data series collected by health facilities in most, if not all, developing countries may render these data useful for early warning purposes. The deseasonalized, adjusted prevalence of malnutrition among children under five years of age seen at a health clinic in Niamey was clearly out of the "normal" range of variability and still on the increase early in 1984, months before official governmental and international recognition of a potential food emergency. Indeed, significant quantities of food aid did not arrive until almost one year later, long after the famine was full blown.

FIG. 6. Predicted probability of famine-deseasonalized proportion of weights below -2 SD less weighted morbidity values

It is also of interest to note that prices, commonly advocated as the most appropriate early warning indicator, appear to have been sensitive but not specific to famine in the Niger case. The dramatic price increases in the early 1980s appear to have been more a function of a short-lived economic boom than of an impending famine, although we are unable to pinpoint the causes of these price rises with any degree of precision. Although malnutrition increased during this period as well, probably because the poor are vulnerable to price increases irrespective of their causes, the increase in the prevalence of malnutrition was distinctly different in magnitude during the 19841985 period. Thus, malnutrition prevalence was relatively sensitive and specific vis-à-vis staple food prices during the period studied, while grain prices were only sensitive.

The logistic regression analysis confirmed the discriminatory power of morbidity-adjusted malnutrition prevalence as a relatively sensitive and specific indicator of famine. However, because of the relatively limited length of the study period and the limited number of clinic observations, the methodology needs be applied to other settings or to the same setting over a longer period of time in order to test its utility more fully.

A point that warrants emphasis concerns the nature of the data series considered in this study. The anthropometric data came from only one clinic, which is one of the largest clinics in Niamey and serves a relatively stable population in an older section of the city. The expected direction of any bias resulting from having a more stable (and possibly more economically advantaged) catchment population would be to decrease the utility of these data for early warning purposes to the extent that increases in the prevalence of malnutrition appear earlier in more vulnerable populations. In actual application, targeting a lower-income segment of the population would likely increase the sensitivity of the indicator(s). The problem of the limited number of clinics in the sample can only be addressed through future research.

It should also be noted that the data analysed in this study are typical of those found in public health systems in developing countries; that is, they are likely to be subject to a variety of errors and inaccuracies. Our findings suggest, however, that with appropriate summarization and estimation techniques, such data may nevertheless be sufficiently accurate to provide meaningful early indications of food stress situations.

In conclusion, this research demonstrates the potential utility of clinic-based nutrition status data for early warning purposes. In addition, it suggests practical methodological tools for analysing time-series data for these purposes.

References

1. Mason J. Habicht J-P, Tabatabai H. Valverde V. Nutrition surveillance. Geneva: WHO, 1984.

2. Webb P. Braun J. Drought, food shortages, and famine in Ethiopia: a preliminary review of effects and policy implications. Washington, DC: International Food Policy Research Institute, 1989.

3. Kelly M. Analysis of nutritional status and market price data from Wollo Region, Ethiopia. 1990. Mimeo.

4. Beaton G. Kelly A, Kevany J. Martorell R. Mason J. eds. Appropriate uses of anthropometric indices in children. Geneva: ACC/SCN, 1990.

5. Tabatabi H. Analytical methods for nutritional and socioeconomic data. Cornell Nutritional Surveillance Program Working Paper no. 6. Ithaca, NY, USA: Cornell University 1983.

6. Sen A. Poverty and famines. Oxford: Clarendon Press, 1981.

7. World Health Organization. Measuring change in nutritional status. Geneva: WHO, 1983.

8. Robinson D, ed. Epidemiology and the community control of disease in warm climate countries. New York: Churchill Livingstone, 1985.

Country report: Maternal and child health and nutrition status in Mongolia - Yongyout Kachondam and Sakorn Dhanamitta

Abstract

Information on the health and nutrition status of mothers and children in Mongolia was gathered during a recent consultancy supported by UNICEF in collaboration with WHO and the Mongolian Ministry of Health. Data were collected from published and unpublished documents, interviews with Mongolian nutrition and health specialists and UNICEF country representatives, and observations using rapid assessment procedures. The four main nutrition problems found were protein-energy malnutrition, vitamin D deficiency, iodine-deficiency disorders, and irondeficiency anaemia. Also of great concern is an extremely high level of acute respiratory infection among young children, which may be attributable in part to the Mongolian lifestyle.

Editor's note

Little is known about the nutrition situation in Mongolia. The Food and Nutrition Bulletin is therefore pleased to publish this report on the nature and magnitude of nutrition-related health problems in the country.

Introduction

As Mongolia is currently going through an extremely difficult period of economic transition characterized by shortfalls of production in almost all sectors, the UNICEF East Asia and Pacific Regional Office (UNICEF/EAPRO) assumes that Mongolian children are likely to suffer the most from the impact of reduced income and food availability aggravating problems associated with malnutrition. Continual monitoring of the health and nutrition status of children and women is therefore regarded as a priority.

UNICEF/EAPRO sent a consultant team from the Institute of Nutrition at Mahidol University, Thailand, to Mongolia, 16 June-7 July 1992, on a mission to collaborate with UNICEF, WHO, and the Mongolian Ministry of Health in documenting the magnitude of health and nutritional problems affecting mothers and children and to assist in designing and initiating a national nutrition survey as well as a nutrition survey of children, using rapid assessment procedures (RAP), to be carried out during July and August 1992 in conjunction with a WHO-sponsored household survey on the control of diarrhoeal diseases. This report synthesizes the team's major findings as obtained from published and non-published documents, interviews with Mongolian nutrition and health specialists; and UNICEF country representatives, and observations with in-depth interviews held as part of a two-day RAP investigation. Its objective is to make these data more widely available and to serve as a guide for researchers and international development agency personnel in helping Mongolia develop specific food and nutrition intervention programmer.

The health care system

The health care system is the responsibility of the Ministry of Health. Mongolia fully supports the concept of primary health care and is one of the signatories of the Alma Ata Declaration and its 'Health for all by the year 2000" proclamation. It has given special attention to strengthening the health manpower available in order to meet the primary health care challenge realistically. Thus it enjoys an impressive ratio of health personnel to the population: its ratio of 39 physicians per 1,000 population is among the highest in Asia. Nearly 100% of births are hospital deliveries, and 95% of the population have access health services. Health care is free of charge with the exception of drugs prescribed for children over three years of age and adults outside the hospital. However, because of the present economic crisis, the Ministry of Health faces a formidable task to maintain its present health care system with little external assistance. Operating costs are currently 6% of the national budget.

The health care system comprises five referral levels, based on the government's social and administrative units. Rural health care is obtained through feldsher units, from which care goes out to nomadic peoples. At the district (somon) level, small medical units with 10-15 beds are served by two or three doctors. Inter-district hospitals (40100 beds) provide services for two or three districts and have some specialists on their staffs. Provincial (aimak) hospitals (250-450 beds) give more specialized services at the provincial level, including surgical and dental care. Lastly, republic hospitals in the capital city of Ulaanbaatar provide tertiary care with full medical and surgical specialties.

Although the health service structure and health personnel force are extensive and adapted to the needs of the population, the recent economic crisis that arose out of abrupt reforms and the discontinuation of external aid (especially from the former USSR) has caused serious concerns regarding maternal and child health. Unemployment may be as high as 14% at present, while food and other basic commodities are increasingly difficult to obtain. Shortages of fuel and spare parts impair transport, power generation, and other essential services. If these problems are not alleviated, they may result in severe hardships for most families, especially during the relentless winter. Those who live in urban areas and depend on rapidly failing distribution systems may be particularly affected.

Child health status

Mortality and morbidity

Overall child health status in Mongolia is relatively good compared to many other less-developed countries. The proportion of children under five years old is relatively high, around 15%. Perinatal and neonatal mortality, as reported by the Ministry of Health in 1988, were 12.7 and 22.2 per 1,000 live births respectively. Considering the high levels of antenatal care and hospital delivery, these mortality levels should be regarded as exceedingly high. Birth trauma was the third highest cause of perinatal death (23.9%), while respiratory tract infection was the highest (28.8%). Infant mortality ranged between 64.9 and 78.9 per 1,000 live births during 1979-1988, which indicates considerable room for improvement. More than half of this rate was due to acute respiratory tract infection. The under-five mortality rate is officially reported to be 84 per 1,000. Limited morbidity statistics for children under three years old attending crèches in the industrial cities showed that the major diseases were pneumonia, diarrhoea, and conjunctivitis.

Of great concern is the extremely high level of acute respiratory infection among young children, which may be attributable to the Mongolian lifestyle. Many families live in a large, single-room tent (ger), heated by coal-burning stoves with poor ventilation, especially during the winter. Conditions are excellent for the transmission of airborne bacteria. Poor hygienic conditions, a characteristic particular of ger dwellers compared to those living in flats (which contain better heated rooms, proper water supplies, and sanitary facilities), may contribute to the higher prevalence of diarrhoea in the summer (>80% versus <30%) and respiratory infection in the winter (80% versus 40%).

The RAP investigation found that the traditional practice of tightly swaddling small children for almost the entire time during winter months not only contributes to vitamin D deficiency (as noted below) but may also be conducive to respiratory infection and a high case fatality rate. Swaddling is so tight that it limits lung compliance and the body's shivering reaction. Further, no layer of air is allowed in as a natural insulator. Instead of providing warmth, therefore, the practice may cause hypothermia.

Immunization coverage

Immunization coverage has increased to well above 80% for all antigens given, according to the Ministry of Health monthly report. This has also coincided with reductions in reported morbidity from the six diseases covered by the Expanded Programme on Immunization (EPI) over the past decade. However, a national EPI review in 1990 found rural coverage to be inflated by as much as 40%. Since viral hepatitis is quite rampant in Mongolia, WHO has agreed to supply hepatitis B vaccine for infants, to be incorporated into the EPI programme. It is important to note that, because of the country's chronic shortage of foreign exchange, it certainly is not feasible for the Ministry of Health to shoulder the cost of EPI for some time to come.

Maternal health status

Maternal and child health care is one of the better developed sectors, with frequent antenatal care and more than 95% coverage. According to the Ministry of Health in 1988, the prevalence of high-risk pregnancy was 22%, with 98% of deliveries taking place in the hospital. Approximately 22% of pregnant women were anaemic The stillbirth rate was 13.6 per 1,000 live births, while the low-birth-weight rate (<2.5 kg) was quite low, 3.4% of newborn infants. Since low birth weight can be used as a proxy indicator reflecting the nutrition status of pregnant women, Mongolia's rate implies that the majority of pregnant women do not have macronutrient deficiencies. This hypothesis, though, should be subject to further study.

It is quite surprising that with such an impressive level of antenatal care, maternal mortality was 144 per 100,000 live births in 1988, about ten times the level recognized as tolerable by WHO. Even worse, the national average masked a tenfold variation between the best and worst provinces. Post-partum haemorrhage has been identified as the major cause of maternal deaths.

Women in Mongolia have the same legal right as men in participating in every branch of the economy, and 86% of women work outside their home. Thus, women take a heavier burden as the bearers and caretakers of children. The total fertility rate in 1990 was 4.9 according to UNICEF statistics [2]. Since contraceptive measures are not available to the majority of women, the first pregnancy usually occurs early in marriage, followed often by other children with short birth intervals. It has been recognized, although there is no solid scientific evidence, that the combination of domestic demands and occupational work together with multiple pregnancies with little control over birth spacing can result in unnecessarily high levels of morbidity and mortality in pregnant women. Once again, this is an area for future research by national and international investigators.

The nutrition status of children and women

Data on the nutrition status of Mongolian children are quite limited. A recent 1990 UNICEF report [1] and other sources [2] state that there are four main nutritional problems: protein-energy malnutrition, vitamin D deficiency, iodine-deficiency disorders, and iron-deficiency anaemia. There is no recorded evidence of other nutritional deficiencies, largely because few systematic epidemiological surveys have been conducted. Little is known, for instance, about vitamin A deficiency.

Protein-energy malnutrition

An anthropometric assessment of preschool children conducted by UNICEF in 1989 showed that the rates of low weight for age (based on Gomez's classification, 90% of the median as cut-off point) among children 0-6 years old of flat dwellers, ger dwellers, and residents of South Gobi Province were 15%, 20%, and 19% respectively [1]. These are in contrast to the national level of 6.1% in 1988. The rates of moderate to severe malnutrition, using the weight-for-age indicator, in children 12-23.9 months old among these three groups were 4%, 7%, and 26%.

Using Waterlow's classification of wasting (weight for height < 80% of the median) and stunting (height for age <90% of the median), the main problem was stunting, which ranged from 10% to 14% among children over one year old for flat dwellers and from 10% to 18% among tent dwellers. No cases of wasting occurred in either group. The main cause of the problem would appear to be chronic energy deficiency or inadequate food consumption after weaning.

Vitamin D deficiency

Rickets is known to be a widespread problem in Mongolia. It is so prevalent that some of the paediatricians participating in the mission's survey believed that all preschool children have rickets. The usual assessment is based on clinical signs, e.g., soft skull (cranio tabes), pigeon chest, bow legs, or knock knees. Mongolian doctors believe that the condition is associated with depleted maternal supplies of calcium, leading to low vitamin D levels in the breast milk. This is an issue that needs further investigation. As noted above, children, especially those under one year old, are almost totally swaddled during the long winter (for 6-8 months). This most likely aggravates this situation, since it precludes them from exposure to sunlight, a natural source of vitamin D.

Iodine-deficiency disorders

A characteristic of landlocked mountainous countries is a shortage or absence of iodine. It is not surpricing, therefore, that there is evidence of low levels or absence of iodine in water and food products in many parts of Mongolia. A 1992 report [3] reveals that micronutrients such as iodine and cobalt are scanty in plants, soil, and drinking water. An analysis of the iodine content in food products showed that eggs, chicken, kidneys, and peas had relatively high levels of iodine, but milk and meat were low in iodine. The Mongolian diet is based largely on meat (beef, mutton) and milk; very few Mongolians have the opportunity to eat eggs, chicken, and peas.

Goitre rates among schoolchildren in Ulaanbaatar showed a rising trend from 1967 to 1991. Although overall rates ranged between 22.7% and 45.8%, with an average of 33.9% in 1991, combined grade-2 and grade-3 rates increased from 2.3% in 1967 to 10.4% in 1991. Geographical differences in goitre prevalence were evident. South Gobi has the lowest goitre prevalence (1.9% in 1992), while Selenge in the north (32.8% in 1991) and other provinces (Oevoerkhangai, Arkhangai, Zavkhan, and Khoevsgul) should be considered goitrous areas. While goitre is endemic in the central and northern areas of Mongolia, Ulaanbaatar is the endemic focus. Factors contributing to this situation include rapid urbanization and population growth. Moreover, food coming to the nation's major cities originates in areas where the soil has a low iodine content. There is also an absence of iodized salt and water, and the nation lacks a concrete control programme for iodine-deficiency disorders.

Iron-deficiency anaemia

The nature and extent of nutritional anaemia have yet to be determined. There are indications that iron-deficiency anaemia is a problem among mothers and children. Lack of food variety and seasonal availability and shortages of fresh fruits and vegetables may contribute to iron and folate deficiency. Multiple pregnancies and a high rate of spontaneous abortion and stillbirths may be factors giving rise to frequent blood loss and iron deficiency. The Ministry of Health also reported 20% anaemia during pregnancy in 1988.

Conclusion

While Mongolia is often viewed as a distant country with little contact with the "outside world," like most nations that have become dependent on external aid, it is feeling pressure from the world's changing economic and political scene. Though the country has made great strides in developing its health infrastructure, it is now facing an uphill battle due to the abrupt unexpected economic and political changes caused by the collapse of the USSR.

Now more than ever, international technical assistance is needed to build the nation's manpower capabilities and resource base to meet existing health and nutrition challenges. Under its current situation, the lessons and principles learned from other countries in maximizing health resources must be identified and tested in Mongolia. Special efforts are needed in such key areas as community nutrition, food production and processing, nutrition communication, and research methods for collecting, analysing, and combining qualitative and quantitative health/nutrition data in order to combat persistent and newly emerging nutritional disorders efficiently and effectively.

Acknowledgements

Funding for this consultancy came from the UNICEF Mongolia Country Programme and the UNICEF East Asia and Pacific Regional Office, Bangkok, Thailand. Appreciation is extended to Dr. Kothari, Senior Regional Planning Officer, Dr. Lay Maung, Senior Advisor for Health and Nutrition, and Mrs. Suchada Saengsingkeo, Senior Programme Officer, who provided important background materials and assistance. Without their commitment, the consultant mission would not have materialized. A special note of gratitude goes to Dr. Oyunbileg, Director of the National Nutrition Center in Mongolia, and Dr. Battumur, Health Program Manager of the Ministry of Health, who arranged and organized the data-collection process. Many thanks also go to Mr. Lyndon Brown, UNICEF Resident Project Officer in Mongolia, who devoted his total attention to our needs during the mission. We are also grateful to Mr. George A. Attig, Technical Advisor to the Institute of Nutrition in Thailand, for his crucial assistance in preparing this article.

References

1. An analysis of the situation of children and women in Mongolia-1990. Ulaanbaatar: UNICEF, ROSCA New Delhi, and the Mongolian Ministry of Health, 1990.

2. Mongolia Annual Report. 1991. Bangkok: UNICEF/ EAPRO, 1991.

3. Radnaabazar J. Goiter and iodine deficiency in Mongolia. Ulaanbaatar: Department of Human Genetics, Maternal and Child Health Research Centre, 1992.

4. Yoddumnern-Attig B. Attig G. Kanungsukkasem. Incorporating explanatory models in planning nutrition education programmes in Thailand. Nutrition and Health 8(1):17-31.

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