Tuesday, July 25, 2017

Lessons in nutrition

Priyadarshini Roy

Most of summer of 2015 was spent in villages of Jhalawar, a district in Rajasthan. It was only a month that our flagship program, Akshada, was launched. The main objective of the program is to improve the maternal health, child health and nutrition indicators. Hence it was important to speak to the mothers to understand practices around health and nutrition.
Every day we would meet groups of women. Younger women with babies in their arms were eager to interact. The older women would typically trickle in later and make statements – often complaining about ideas like ‘rest during pregnancy’ by the doctors. They thought such advice had ‘spoilt’ the younger women. They would often say that now-a-days young women do not have the kind of strength that they possessed in their youth.
I would ignore such statements because they were not responses to our questions- what do young mothers feed their children, what do they have during their pregnancy, are there any foods that they avoid during pregnancy, etc. However, similar responses from the older women, village after village got me thinking. I added a few questions and things to observe in my discussion guide from week two.
During the focus group discussions, I started noticing the difference. Most of the younger women in their colourful attire looked frail, tired and weak. They lacked that energy which is often synonymous with youth and being pregnant. The older women despite their slow and assisted movement, appeared well-nourished and not over-weight. Their wrists were broader and they seemed to have substantial muscle mass, as compared to the younger lot.
We started probing and comparing food habits during pregnancy of younger and older women. There was a significant change in diet over the years. The older women ate what they grew- whole grains and greens. Their diet comprised of curd and buttermilk in good quantities. On the other hand, the younger women bought cereals from the market, which was more than often not grown in their villages. In a couple of decades or so maize, millets, barley were replaced by wheat and rice. Today’s diet included more of processed food, especially in case of children in the weaning age-group.
Some basic ways of life had changed drastically. Majority of farmers are growing cash crops. Therefore, their daily diet had changed. With better access to cities, processed food has made its way into the lives of families in rural areas. And how! When a young mother was asked what does she feed her 8- month old child, besides breastmilk, she said “One packet of Takatak and a few Parle-G biscuits. He eats all of it. Does not want to have roti”. Takatak is the Kurkure equivalent in rural Jhalawar. This is what we heard in almost 75% of the villages that we visited. The older women told us that they ate maize rotis and maize porridge during pregnancy and when weaning a child, they would give them small and diluted portions of the same diet. Locally grown grains and vegetables were the main ingredients.
A lot had changed in two and a half decades- agricultural practices, food habits, perception of nutritious food, etc. It was also clear that providing interventions during the 1,000 days is just not enough. A comprehensive strategy needs to be deployed to tackle undernutrition. Policies related to agricultural practices are as important as pricing/taxing policies of junk food to create an environment, where healthier options are available. For example- farmers to compulsorily retain a fraction of their land to grow traditional food crops, fruits and vegetables. Only then can the remaining land be used for commercial production. Fast foods that have no or very little nutritious value should be taxed at a higher rate to discourage intake.
Lesson learnt: Do not ignore statements or comments made by onlookers during a focus group discussion as they may provide cue to rich data. When we began, I was clearly not listening!

Priyadarshini Roy is Director-Programs with the Antara Foundation

Tuesday, July 4, 2017

Nursing is my superpower

Ratan Kunwar 

It is a typical summer day in Jhalawar, Rajasthan. The journey to the field is long and bumpy and yet the landscapes, so well anchored in time, offer an extravagant simplicity beyond any polished beauty. We are here to meet and better understand the work and life of Ratan Kunwar, a young ANM posted in Moondla sub-center of Khanpur Block in Jhalawar District of Rajasthan. She has been providing healthcare services for over a year now.
How did you get involved in this work?
I was lucky to have been given a proper education, unlike many girls in my village. When I graduated, the next step was finding a job to earn for my family. Who knew that one day, following my friends to fill out a form for healthcare services would change my life for the better.
What is a work day in your life like?
I live with my elder brother and his wife, so I wake up at 5:30am every day to help my sister-in-law with household chores. After that I set out on my scooter to the field, covering about 70-80 km every day. I am in-charge of 11 villages and take care of the VHND (Village Health and Nutrition Day) where I perform vaccination of pregnant women and children. My work also includes tasks such as counselling high risk pregnant women, home-based post-natal care, and motivating couples to maintain a gap of three years between two kids. I return by 5PM to 6PM in the evening.
What are some challenges that you face in carrying out your work?
In a population of 5,257, there is a substantial population (1,230) of scheduled tribe and scheduled castes. For most part of the year, they migrate from one place to another in search of work. This makes it difficult to track them for vaccination as they keep changing their phone numbers as well.
One case where you felt you were instrumental in saving a life?
Once during a woman’s ANC check-up, I discovered that she had an increased blood pressure. Her sonography revealed that her baby had died in the womb (intra-uterine death). I referred her to the district hospital in Jhalawar, which is more equipped with skilled staff to deal with such cases. She insisted we deliver the foetus there but I counselled that her life would be at risk if she does so. In the end, she delivered her foetus safely at the Jhalawar district hospital. She was understandably distraught and blamed us for the death of her baby but I am only thankful that I could save at least one life that day. Her life.
How do you believe we can achieve substantial improvements in maternal health?
I think that a regular training of the frontline workers can improve things in the villages. I oversee 11 villages and I don’t mind confessing that I need help. Having another ANM would ensure that not a single beneficiary is left out.
Before Ratan got posted in Moondla, the position lay vacant for two years. When she joined, she was welcomed with phrases such as, “finally someone is coming to vaccinate our women and children” and “we were unaware of the government’s provisions and services”. It is these sentiments of people which motivate her to continue her work and provide better healthcare.

Ratan Kunwar is an Auxiliary Nurse Midwife in Moondala, Rajasthan

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