Igniting Women’s and Local Bodies Convergence: Towards Improving Maternal Health and Nutrition Services in Rural India
Authors: Neelmani Singh a public health professional with more than a decade working experience in Nutrition program. Anand Kumar is a Public Health Professional in India with a decade working experience in Urban Health, HSS & RMNCH+A Services in India. Sanjeev Kumar is a public health professional with a decade working experience with multiple State Health Systems in India.
Malnourishment has long been silent emergency in India. Evidence suggests that there are several factors, working independently or in combination, that are responsible for poor nutritional status among the women in Indian populace. These include lack of access to adequate and nutritious food, poor hygienic practices, infections such as diarrhoea and helminths, and gender and class disparities. Due to which, it is seen throughout the life cycle and is most acute during childhood, adolescent age, pregnancy, and lactation.
From a nutritional perspective, pregnant and lactating women are among the most vulnerable groups. Therefore, these groups of women must be provided an adequate supply of micronutrients since the preconception period to ensure optimal nutrient transmission to the foetus and, in turn, to the yet-to-born offspring. Evidence also suggests that the maternal nutrition during antenatal significantly affects foetal growth and pregnancy outcome. Moreover, a significant association was found between chronic undernutrition and pregnancy outcome – both for the mother and the offspring, for example -In India, 20% of babies born annually are as low birth weight (LBW).
The Union and State Governments in India are constantly striving to improve the nutritional status of women of reproductive age. The efforts have yielded a significant reduction in women’s undernutrition, but problems of overweight and obesity continue to rise in this demographic section. The National Family Health Survey 2015-16 based study entails that the double burden of malnutrition (Undernutrition and Obesity) among mother-child pairs in India is 6%.
The continuum of Care approach is central to all nutritional interventions for women. In 2013, the Government of India adopted the continuum of care approach and developed a strategy for Reproductive, Maternal, New-born, Child, and Adolescent Health (RMNCH+A). Under which, one of intervention is Iron and Folic Acid supplementation, which is a highly effective intervention to fight malnutrition, distributed to adolescents and to pregnant women during Antenatal Care Check-ups.
In 2019, the Government of India developed a strategy to eliminate Anaemia (Anaemia Mukt Bharat) under the Prime Minister’s Overarching Scheme for Holistic Nourishment (POSHAN) Abhiyaan, to accelerate the anaemia reduction rate (less than 1% between 2005-2015). This strategy has enabled the health system to resolve supply-side barriers in many ways. Intensifying demand generation through year-round Behaviour Change Communication (BCC) Campaigns is one of them. It could be further scaled through convergence between the different community health and non-health programs, with width and depth.
National Livelihood is a non-health program with a community-level women’s Self Help Group (SHG) network. In Bihar, one of such network, called, JEEVIKA), has wide availability throughout the state. Such groups are self-governed and empowered to plan and execute activities for their local needs. Jeevika group members belong to the local communities, so rolling the BCC interventions using this platform could be effective, considering the enhanced acceptability of local voices to the local population. As Jeevika facilitates women for income generation and accessing the benefits of social protection schemes. Further this platform of SHG could be extended for organising Annaprasan (weaning ceremony), Saas-Bahu sammelan, and distribution of Nayi pahal kit (Family Planning Kit meant for the newlywed).
Local governance bodies, including Panchayati Raj Institutions, significantly influence health & its determinants, including nutrition services in communities. So, the members of such institutions reaching out to the communities for nutritional services would be prudent in generating demand for women-specific nutritional services/ practices.
The aforementioned local governance bodies and SHGs are the essential links between the rightsholders and the duty bearers who can improve the coverage, continuity, quality, and intensity (C2IQ) of community health & nutrition programs. Such institutions can raise community awareness on its rights and responsibilities and avail the nutrition-related services within community. It could also be prudent in uprooting the misbeliefs, misconception about the nutritional interventions.
The union and state governments recognized the local governance bodies and SHG as the change agents towards improving “Community based nutritional services for women”. Resilient intersectoral coordination between the existing primary care avenues and these change agents could be highly effective in generating demand for community based nutritional interventions.
Village Health Sanitation & Nutrition Committee (VHSNC) is one such avenue at the “revenue village” level, which is empowered to make health and nutrition plan for the local need. In the committee constitution, it is mandatory to have representation from local bodies. Under this committee ambit, Village Health Sanitation and Nutrition Day (VHSND) is provisioned to be organized monthly in every village. On this day, the respective Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwife (ANM), Anganwadi Worker (AWW), SHG leader, Parent Teacher Association /Mother Teacher Association & village representative of any community-based organisation, including local bodies representative is supposed to gather and deliver their set of activities for health, sanitation and nutrition services. Nudging the women to seek ANC care, adhere to IFA supplementation and address knowledge & food taboos on the importance of diet diversity by SHG leaders could be easily done on this day. Prior evidence also suggests that pregnant women are more likely to adhere to IFA courses if their husband attends ANC. Considering the availability of different community-level stakeholders, this practice of husband companionship during ANC could be easily promoted. It is also highly likely that the better coordination of local bodies, SHG and community health workers can influence the community belief system in much effective way to address malnutrition among women.
Local bodies and SHGs have great potential to impact women’s nutritional practices within communities. Hence, these institutions could serve as significant catalysts in creating demand for community based nutritional services. However, despite acknowledging their potential, establishing and implementing a resilient intersectoral coordination mechanism between local bodies, SHG and primary care apparatus remains a challenge.
Role of women in rural community development is crucial but often ignored or not fully bank on. Our experience of working with rural communities in four villages of Thane District of Maharashtra state in India for empowering them with better and safe sanitation habits, equipped with providing infrastructure, has amply showcased this fact.
Working with in different groups of women based on age further helped us with our behavioral change training. From girl students at the local schools to adult and senior women we had a different approach designed based on their respective pain areas and preferences. Women SHG, women religious groups that devote specific hours for collective activities each week to women working at the farms, we involved each of them from designing the initiative, implementing to check on its status at fixed intervals post execution.
Our participative model involved sweat labour for all the unskilled work in the construction of individual toilet by respective family helped sustainability.
In the patriarchal society in spite of men at the helm with the financial decision making, women if persuaded can turn the men towards common good of their family and in turn the society that we experienced in our Right To Go rural sanitation project.
Today those 5000 men and women use and maintain their own toilet in four villages since last 8 plus years, that’s the power of women involvement.
It’s an interesting article on malnutrition. Kudos to the authors.