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Childhood malnutrition and low birth weight
(birthweight of less that 2500 grams) continue to be major public
health problems in India. With a low birth weight (LBW) rate of
30 percent, India accounts for almost 40 percent of the global burden.
Research has established that LBW contributes to neonatal and childhood
mortality and morbidity, growth and development during childhood,
and to adult disease like diabetes, and coronary heart disease.
Reduction of LBW is therefore, critical to improving infant and
child morbidity and mortality, as well as raising productivity,
and reduce private and public health care expenditures throughout
the lifecycle. Major determinants of low birth weight in developing
countries are poor maternal nutritional status at conception, low
gestational weight gain due to inadequate dietary intake, and short
maternal stature due to the mother’s own childhood under nutrition.
Here a vicious cycle of low birth weight and malnutrition is created
which is perpetuated across generations. Low birth weight thus becomes
a significant cause and a consequence of under nutrition. Clearly,
to break the cycle of malnutrition, there is need to intervene at
critical stages of lifecycle addressing risks and opportunities
during pregnancy and moving through birth, infancy, early childhood
and adolescence. It is well recognised that maternal and child health
services as well as a range of behavioural factors need to work
synergistically to break the intergenerational cycle of malnutrition
and improve these key indicators.
 The
state of Jharkhand in eastern India is predominantly rural with
a large tribal population. With an infant mortality rate of 71,
an immunisation coverage of only about 10 percent, and more than
90 percent home deliveries, combined with an acute shortage and
low utilisation and accessibility of healthcare facilities, the
state provides a context in urgent need of interventions to address
these problems.
The Ranchi Low Birth Weight Project is a quasi-experimental action
research study to evaluate the effectiveness of lifecycle-based
community level behavioural interventions in reducing the incidence
of low birth weight and improving maternal and infant health. Established
in 2002, the project is a partnership with two NGOs, Krishi Gram
Vikas Kendra (KGVK) and the Child In Need Institute (CINI), and
the Government of Jharkhand. While KGVK is a Ranchi based non-governmental
organisation, which has been working closely with local communities
in Jharkhand for more than three decades; CINI is a national NGO,
with presence in multiple states, has evolved a life cycle based
framework for improving key reproductive and child health outcomes.
It has had more than 30 years of experience in community health,
as well as in building proactive partnerships with government and
other civil society stakeholders.
 Covering
a population of around 200,000 across two blocks of Ranchi district
Angara and Sili, the project serves as a learning site for the state
government and has put on ground a rigorous research design and
data collection system to track progress on a number of maternal
and child health outcomes, including primary, community-based birth
weight data. Interventions in the Ranchi LBW project aim to improve
maternal and infant health outcomes by addressing a range of medico-social
and behavioural determinants of low birth weight. It envisages implementing
and evaluating the additive effects of community level behavioural
interventions in bringing about positive improvements in maternal
and infant health outcomes in an area where mandated public health
and related services are ensured.
Two complementary sets of interventions are used in the project:
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- The community based interventions include a hamlet level female
community health volunteer (Sahiyya), who is selected and supported
by Village Health Committees (VHCs), comprising of community
representatives. The quality and type of training is the most
crucial determinant of a CHW’s effectiveness in serving
her community’s health needs. Towards this end, the project
has developed three rounds of training which introduce, in a
phased manner, new knowledge regarding maternal and child health,
public health services, behaviour change communication, and
communicable diseases. Further, in-service training is provided
by trainers visiting the villages and working with the Sahiyyas
to constantly reinforce learnings. The project has also conceptualised
and created a supportive structure for the Sahiyya at different
levels, comprising of the Master Trainer and the Village Health
Committee at the village level, the Supervisor at the cluster
level and the Coordinator at the block level. These cadres of
personnel support the training of the Sahiyya, provide ongoing
support, and supervise and evaluate her work. Equipped with
this training, support structure and the 'cohort register' that
records details about each case, the Sahiyya plays a primarily
preventive and promotive role focusing on changing dietary practices,
reducing workload during pregnancy, availing antenatal care
from health facilities, promoting appropriate child feeding
and caring practices, and building awareness about health and
nutrition issues in her hamlet. Together, the VHCs and the Sahiyyas
act as agents of community mobilisation by facilitating behaviour
change for better maternal and child health practices, preventive
and promotive case management in the area of maternal and infant
health, building ownership and initiating action on community
health issues, and facilitating linking of communities with
health services.
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- At the service delivery level, the
focus is on bridging existing gaps in mandated public health
care delivery by ensuring regular supplies of essential drugs,
provider capacity building which involves orientation and training
of public health functionaries, renovation/ construction of
sub-centre facilities, ensuring availability of emergency obstetric
care through equipped health facilities, and ensuring provision
of medical services in remote and inaccessible areas. The sustainability
of any CHW programme is intrinsically linked to the support
it receives from the public health system. As one of the central
roles of the Sahiyya is to act as a link between the public
health system and the community, the project has undertaken
various initiatives of training, sensitisation and orientation
for public health personnel such as Auxiliary Nurse Midwives
(ANMs), Medical Officers and Anganwadi Workers (AWWs) to support
and facilitate the Sahiyya and her work. The monthly cluster
meetings with participation of Sahiyyas, Master Trainers, Supervisors,
VHC members, ANMs and AWWs illustrate the principles of supportive
supervision, the problem solving approach, collective participation
of the community, linkages with the public health system, and
synergies between the health and nutrition systems at decentralised
levels.
The critical outcome measures of the project include
low birth weight, infant mortality rate, childhood malnutrition,
maternal and neonatal care practices, dietary habits of adolescent
girls and pregnant women, and infant feeding practices. The project
critically examines the processes through which change in such practices
occur in the community, and the role of community agents and health
systems in bringing about this change. It also documents and analyses
the processes of capacity building and engagement of the Sahiyyas
and the VHCs with the public health system.
Since its inception the project has been able to
inform state policies and programmes, and contribute to sectoral
knowledge in some critical areas, such as the selection and training
of CHWs in rural and tribal contexts and with low levels of literacy;
the role of VHCs as community based support structures for CHWs;
the creation of a community-based information system and problem-solving
mechanism through the introduction of a simple pictorial cohort
register and cluster-level meetings; and the synergies and dynamics
between CHWs, VHCs, and local health and ICDS functionaries in altering
the quality of service delivery and its utilisation. These learnings
have been especially valuable for the Sahiyya Programme in Jharkhand
(which aims to introduce hamlet-level CHWs in the state), as well
as for the Accredited Social Health Activist (ASHA) Programme in
the current context of the National Rural Health Mission.
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