Association of Trends in Child Undernutrition and Implementation of the National Rural Health Mission in India: A Nationally Representative Serial Cross-Sectional Study on Data from 1992 – 2015

Background India launched the National Rural Health Mission (NRHM) in 2005 to strengthen its primary healthcare system in high-focus and northeast focus states. One of the NRHM objectives was to reduce child undernutrition in India. Methods and Findings We used data from 1992, 1998, 2005, and 2015 National Family Health Surveys of India to evaluate trends in child undernutrition prevalence before and after NRHM and across different categories of focus states. Stunting, Wasting, and Comprehensive Index of Anthropometric Failure (CIAF) was assessed using WHO growth curves to assess chronic, acute, and overall undernutrition. The study included 187,452 children aged 3 years or under. Survey-weighted and confounder-adjusted average annualized reduction rates (AARR) and predicted probability ratios were used to assess trends and socioeconomic disparities for child undernutrition, respectively. Nationwide, the prevalence of all types of undernutrition decreased from 1992 to 2015. However, the trends varied before and after NRHM implementation and differentially by focus states. After NRHM, acute undernutrition declined more rapidly among high-focus states (AARR 1.0%) but increased in normal-focus states (AARR -1.9% per year; p<0.001). In contrast, the prevalence of chronic undernutrition declined more rapidly (AARR 1.6%) in the normal focus states in comparison to high-focus states (0.3%; p=0.01). Income and caste-based disparities in acute undernutrition decreased but did not disappear after the implementation of the NRHM. However, similar disparities in prevalence of chronic undernutrition appear to be exacerbated after the implementation of the NRHM. Major limitations of this study include the observational and cross-sectional design, which preclude our ability to draw causal inferences. Conclusion Our results suggests that NRHM implementation might be associated with improvement in wasting (acute) rather than stunting (chronic) forms of undernutrition. Strategies to combat undernutrition equitably, especially in high-focus states are needed. Why was this study done? What did the researchers do and find? What do these findings mean? ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement AS received support from the National Institute of General Medical Science (T32GM107000), National Center for Advancing Translational Sciences (TL1-TR001454) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1F30HD091975-03). TMS received support from the National Center for Chronic Disease Prevention and Health Promotion (5U01DP006093-04). JA received support from the National Institute on Minority Health and Health Disparities (P60-MD006912-05). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The University of Massachusetts Medical School IRB reviewed the protocol for the secondary data analyses presented in this manuscript. This study was deemed exempt from full review because the data contained no personal identifiable information on survey participants. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data used in this study are available publicly and free of cost to registered users through the DHS website ([www.dhsprogram.com][1]) and Integrated Public Use Microdata Series-DHS, a grant-based initiative to promote microdata analyses of DHS datasets ([www.idhsdata.org/idhs/][2]). [1]: http://www.dhsprogram.com [2]: http://www.idhsdata.org/idhs/