In Mumbai slums, children do not have bulging bellies or weak legs, the tell-tale signs of malnourishment. They look frail — being underweight is a secondary trait for them. But the absence of the most visible traits makes diagnosis difficult in a city that has a worrisome count of 2,886 severely acute malnutrition cases.
Between July and August this year, the Integrated Child Development System (ICDS) recorded 12 deaths in city slums, all of infants less than one year. One was classified as a malnutrition death, five were stillbirths, and six died due to infection. The Indian Express visited the homes of all these children. In all cases a common trend lies: underweight mother, multiple children, low weight of the babies during birth, poor sanitation, and illiteracy about nutrition requirements.
While Palghar has come under the spotlight for high malnutrition cases, the scenario in Mumbai is grimmer — children are falling prey to it despite easy access to health services that Palghar’s tribal hamlets lack. Despite four medical colleges, 21 peripheral hospitals and 5,130 anganwadi centres, the city has 51,934 undernourished kids, latest data from the ICDS shows.
“It’s a vicious cycle. Young girls marry early and get pregnant. Multiple pregnancies lead to premature delivery and low weight of babies, which make them prone to a host of infections,” said Dr Alka Jadhav, professor of Paediatric Department at Sion hospital. Of the 12 children who died, four were the third or the fourth child in their family.
Sion hospital receives 150 children in its paediatric department daily. Compulsory screening of all children shows at least 30 per cent are malnourished. According to NGO Apnalaya, however, the figures are higher. In Shivaji Nagar, Apnalaya found 47 per cent children underweight, 60 per cent stunted, and immunisation reaching only 61.8 per cent children in 2016.
Between July and August, there were three stillbirths in Shivaji Nagar and two in Bhandup. Apnalaya data showed a whopping 94 per cent pregnant women in Shivaji Nagar were anaemic. “If a pregnant woman is anaemic, the oxygen supply through her heamoglobin to the foetus reduces and the child’s growth in the uterus is affected. This can result in a stillbirth,” Dr Jadhav said.
According to Disha Gade, dietician at the city’s only Nutrition Rehabilitation, Research and Training Center (NRRTC), a severely acute malnourished child (SAM) is nine times more prone to catch infections.
Low weight of the mother, anaemia and multiple pregnancies are contributing factors towards the baby’s undernourishment. Migration is another. In six out of 12 deaths, the families would go back to their villages for months at a time.
Dharavi, Mankhurd, Shivaji Nagar, Khar East and Santacruz East have the highest malnutrition burden. These are also areas with the maximum migrant population. “Even if we improve children’s weight by free dietary supplements, once they are taken back to their villages, they slip into the SAM category again,” said Supriya Lahane, supervisor of Baiganwadi, Govandi.
With frail limb, constant tiredness, and pale eyes, Tamanna Gujjar (4) weighs only 12 kg. Her younger sister Dishali, a SAM child, passed away due to lose motions and vomitting in July after malnutrition lowered her immunity. In Baiganwadi, despite an anganwadi right next to their house, Tamanna is neither taken for counseling nor for treatment to a hospital. She has been a moderately acute malnourished (MAM) child since July 2015. Since 2015, she has lived in Mogana village in Rajasthan for eight months, making continued treatment impossible either in Rajasthan or Maharashtra.
“How do we improve her weight?” an exasperated Meenakshi Mandore, anganwadi worker, said. While a SAM or MAM child is given ‘take home ration’ (THR) for free by ICDS, Tamanna does not eat it.
The government-funded THR has been rejected by many like her due to its poor taste. While experts claim it is full of nutrition, it has not been accepted even by financially disadvantaged families.
There is also an urgent need for trained counsellors to educate slum dwellers on the importance of nutrition. Anganwadi workers lack that skill. In Gaondevi slum, Vakola, grocery shops stand displaying packets of chips and snacks — most of their buyers being children. “Slum women work during the day. Since they have no time to cook, they often leave their children with money to buy chips. Children fill their stomach with junk and refuse to eat home food,” Sushma Shinde, attached with Sneha NGO, said.
Of the 205 posts for trained supervisors sanctioned by ICDS, 55 are vacant. In 5,130 anganwadis, 117 teachers are missing.
July 3. In Govandi, Baiganwadi
When Dishali Gujjar (1) died, she weighed merely 4 kg — half of the WHO standards for a child her age. A case of severely acute malnourishment (SAM), she was born weighing 900 gram. “She kept vomiting and had loose motions the day before she died,” said mother Manju Gujjar (26).
Migration and early marriage were the biggest factors behind the baby’s weak health. Manju was married at the age of 13. For three months after her pregnancy, she was back in her village in Rajasthan. According to anganwadi worker Meenakshi Mandore, Dishali could never be pulled out of SAM category because Manju would migrate to Rajasthan for several months without consulting the anganwadi.
The Gujjars have a two-storey house in Baiganwadi slums. Despite a steady income, the child was not admitted to the Nutrition Rehabilitation Center even once. Dishali, born in August 2015, would mostly remain inactive. “I showed her to a local doctor in the village,” Manju explains. The Baiganwadi’s anganwadi centre also did not counsel the mother repeatedly over the child’s nutrition requirements. “She was in the village most of the time. That is the difficulty we face with most women here,” Mandore said.
August 5: Vakola, Gaodevi
It was security guard Sudesh Jadhav and wife Swanranjal’s third boy after two girls. He died two days after birth due to low weight and a weak immune system. Swaranjal (30) had typhoid when she was pregnant. Later she contracted tuberculosis. Her weight was only 37 kg during pregnancy. Nineteen days after delivery, she also passed away.
“We tried to keep her enrolled with us for counselling but she would keep shuttling between Vakola and her mother’s house in Vashi,” angawadi worker Bhavna Deshmukh said.
Swaranjal delivered her child in the seventh month of pregnancy. For the seven months, she neither consumed folic acid tablets to build up iron nor did she visit the local anganwadi for counselling.
The Santacruz and Khar East ICDS office has 940 pregnant and lactating mothers and 8,802 children registered, for whom there are only 220 anganwadi teachers available. Slum dwellers such as Swaranjal require constant follow-up, which an already overburdened anganwadi worker may find difficult.
“She did not tell me about TB. Had I known, I would have suggested measures she should have taken during pregnancy,” Deshmukh added.
Swaranjal’s two daughters, Srushti (2) and Sanjita (5), were registered with the anganwadi. Since their brother and mother’s death, the family has moved back to Dapoli. Now, even the two girls are off the radar.
“There is no system in ICDS where supervisors of other districts can be informed about children migrating to their areas,” said Anita Kohlekar, supervisor in Santacruz East.
August 12: Khar East, Huseni Gali
Hamida and Jameel Shaikh’s son was their third child. He died three days after birth due to infection at Bhabha Bandra Hospital, where he remained admitted on ventilator for two days. Hamida (30) delivered him pre-term in her eighth month of pregnancy. She suffered from anemia, low blood pressure and a skin infection during her pregnancy. Her two daughters, aged six and three years, weigh normally. The son who passed away weighed 2.4 kg, pre-term and below the required 2.5-kg weight.
Jameel, a driver, claimed that the boy had breathing problems but his health worsened on the second day of birth. “We paid `14,000 for an injection to the hospital when doctors told us his lungs were not fully developed,” Jameel said.According to anganwadi worker Sandra Albert, the mother was provided free folic acid during her pregnancy from the third month. Albert has over 30 children under her care in anganwadi.
In Santacruz and Khar East, of the 93 children born in August, eight were born with low weight. During the monsoons, loss of weight in children is common due to infections spread by poor sanitation and water logging in slums.
July 27: Govandi, Baiganwadi
Nasreen Shaikh’s daughter died eight days after birth. The baby was born underweight, weighing 2.3 kg. She was taken from Sion hospital to a private hospital in Baiganwadi, then to J J hospital and finally admitted at Nair Hospital, where she eventually died. According to Shaikh, hospitals refused admission to them citing lack of available beds.
At 30, this was her fourth child. She got married when she was 20 years old and had her first baby at 22.
The baby, born on July 19 at Govandi Shatabdi hospital, kept vomiting. “Doctors at Shatabdi Hospital said they could not treat her as the hospital had no ventilator,” Shaikh said. With poor support from government hospitals and delayed treatment, the baby succumbed to infection and breathing problems.
Shaikh had also undergone abortion two years ago, which had further affected her immunity. According to doctors, young mothers suffer weakness and low heamoglobin due to multiple pregnancies. Shaikh’s two children do not take the free THR provided by the government due to its poor taste.
July 9: Govandi, Shivaji Nagar
Mohamed Husain died when he was 11 months old. He was born after Shahin Qureshi (41) had given birth to five children already. The baby died due to a heart condition called cardiomyopathy. His elder brother was also
moderately acute malnourished after birth and another brother was lost in miscarriage.
Husain was admitted in Sion hospital and later Masina Hospital. According to father Salim Qureshi, the baby was too weak to be operated upon and passed away weighing 4.5 kg. Shahin is also anaemic, has low haemoglobin count at 10.7 and is calcium deficient. “A lot of women are not ready to even let us in. It is difficult to counsel them. Shahin stopped taking THR because her children did not like it,” said anganwadi worker Vaishali Patil.
August 31: Bhandup East
Neel Jadhav passed away when he was seven months old due to Guillain-Barré syndrome, a condition that affected his immune system. Days before his death, he was put on ventilator support and had a paralysis attack. According to supervisor S K Pawar, Neel was born with normal weight and was breast-fed upto six months, as per World Health Organization standards. He is the only child to die due to an ailment not caused by nutrition problems in the 12 deaths ICDS recorded.
August 7: Bhandup West
Maria Vinita Selman (30) was due to deliver in November this year. In the end of August, she suffered abdominal pains and was taken to Sion hospital, where she delivered twins, both dead.“During pregnancy, she suffered from vomiting, weakness, and swelling of legs. She left for her village in Navi Mumbai after delivery,” said Anant Narvekar, anganwadi supervisor. Selman’s case is identical to other pregnant women who lost their new-borns due to low weight and constant weakness.
While Selman was provided calcium and iron supplements in the camps conducted by Savitribai Phule hospital, there is urgent need to increase family planning awareness among slum-dwellers.