It is believed that giving birth to an off-spring is the most beautiful experience for a woman. However, across the world today, for millions of women, pregnancy and child-birth remain a rather life-taking risk. Every year, more than 500,000 women die from complications of pregnancy and childbirth. These deaths could otherwise be avoided but for want of better child-delivery assistance, medical facilities to manage an emergency situation, better nutrition and health during pregnancy, etc. Worldwide, more than 50 million women suffer from poor reproductive health and serious pregnancy-related illnesses and disability. Also associated with this phenomenon is poverty which means poor nutrition resulting in poor health, little or no access to professional medical help, lack of awareness about pregnancy related facts, social customs and beliefs which do not allow pregnant women to discuss their problems openly.

A number of population-related initiatives have focused largely on contraception. It has to be realized that in addition to contraception, women need access to a broad range of services. The primary means of preventing maternal deaths is to provide rapid access to emergency obstetrical care, including treatment of hemorrhages, infections, hypertension, and obstructed labor. It is also important to ensure that a midwife, or doctor is present at every delivery. In developing countries only about half of deliveries are attended by professional health staff. Also, these skilled attendants must be supported by the right environment that enables life-saving interventions such as antibiotics, surgery, and transportation to medical centers. Many women may lack the money for health care and transport, or they may simply lack their family's permission to seek care.

What can be done?
The need to educate women in pregnancy-related aspects is more pronounced and established beyond any doubt. A number of studies carried out across the world have shown that education not only equips women to take better care of themselves but also their families. A study by Tufts University to measure the impact of Bangladesh Integrated Nutrition Project on pregnant women's health has reported that education has led to awareness about the need for proper diet in pregnant women. It has also led to addressing some of the prevailing wrong notions about pregnancy. The study also underlines the importance of the education component needing to deal not only with factual information related to pregnancy and nutrition but also needs to concern itself with behaviourial change communications to address the beliefs and practices.

Let us look at an example
Bangladesh Integrated Nutrition Project (BINP) is one of the largest long-term (5-years) nutrition programs designed to funnel resources into a wide array of nutrition projects. One such project facilitated by Tufts University's School of Nutrition Science and Policy was the Newly Married Couples Strategy. The objective of this project was to instill better nutritional habits in young and married adolescent girls before their first pregnancy. The project exemplifies the importance of extending counseling and behavioral change communications to all adult household members, including the mothers-in-law and husbands. In Bangladesh, those most at risk for hunger and disease and those with the least power are teenage mothers and their children. The maternal mortality rate in Bangladesh is nearly 200 times higher than in the United States, and more than 10 percent of children die before their fifth birthday. “Also parents start looking for husbands for girls by the age of 12 and 13 to keep them safe, so there is no danger to the family's honor,” says Thomas Schaetzel, Ph.D. candidate who has worked for six years in Bangladesh and serves as project coordinator for Tufts' activities in Bangladesh. “About half of all girls are married by the age of 15 and have their first child before they themselves have reached maturity. Their bodies never get a chance to catch up.”

Early childbirth is exacerbated by local customs that encourage young pregnant women to 'eat down' or consume even less food than usual. The belief is that if the mother eats too much, she'll have a difficult delivery or there won't be enough room in her stomach for the baby. As a result, roughly 58 percent of these girls remain malnourished, while 40 percent of their babies have low birth weights that are among the highest in the world. The cycle of malnutrition continues in those children who do live past their first birthday as they face increased health risks and a diminished ability to learn and work.

Breaking the Cycle
To break this devastating cycle, Tufts helped develop the Newly Married Couples Strategy in collaboration with the Bangladesh Rural Advancement Committee (BRAC), the country's largest non-government organization. It was felt by the team that if they can instill better nutritional habits in adolescent girls through the Newly Married Couples Strategy before the first baby is bornand encourage the husbands and mothers-in-law to buy into the programthey have the best chance to increase the health of the mothers and children in the long-term.

Initially, project staff would visit the husband and mother-in-law to gain their support for the program. This step was essential in a culture in which young brides have little control over their lives. Young wives are expected to stay home for the first year or two of marriage while the husband does all the errands in the outside worldeven food shopping. As a result, young and marrried girls have little exposure to the outside world and to the health messages the government promotes.

Once the wife is enrolled in the program, a trained woman from the villagea community nutrition promoter (CNP) visits her at home. The CNP measures and weighs her and questions her about her eating habits. Eventually, the young woman is vaccinated and given iron folate tablets to combat the ever-prevalent anemia, which affects about 70 percent of Bangladeshi women of reproductive age. Those who are malnourished are encouraged to meet with other village women once a day to prepare and consume supplemental food produced by local women's groups. Each food packet contains rice, flour, oil, legumes, and molasses fortified with B vitamins and minerals at levels established by Tufts consultants.

Women also are taught to add green, leafy vegetables to the family's usual diet of lentils and rice to increase their Vitamin A intake. Vitamin A deficiencies cause blindness in roughly 30,000 children per year. With the promotion of a diet containing green vegetables and the distribution of Vitamin A supplements, that number has been cut in half.

The community nutrition promoter continues to visit the young wife once a month until her first child reaches age 2. She also monitors the baby's weight and growth, provides supplemental food if the baby doesn't thrive, and makes sure the child is immunized. Throughout their participation in the program, village women receive conseling on proper nutrition and women's health issues, including birth controlnormally a taboo subject for them. “It's possible that this project will have just as big a cultural impact,” says Schaetzel. “These girls are interacting with other young wives and can share their concernslike family planning. They can finally have a link to the outside world.”

The Bangladesh Integrated Nutrition Project has brought unexpected benefits to other village women. More than 88,000 women in BINP villages are paid to produce the food packets, and that provides another source of family income. To date, the project has trained more than 8,000 CNPs in month-long courses focusing on nutrition and health. “Not only were we able to develop a cadre of effective CNPs,” Schaetzel says, “the project has encouraged these women by offering them small salaries that have a major impact on their quality of lifeand by raising their status as respected village leaders.

The next challenge for Bangladesh in its new National Nutrition Programme will be finding the most cost-effective means of reducing beliefs-practice gap among those women successfully convinced by project counseling but unable to translate this knowledge into practice.

Facts:
¡ While the highest number of maternal deaths occur in Asia, the risk of dying is highest in Africa. Recent findings on maternal mortality by WHO, UNICEF and UNFPA show that a woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth.
¡ Women in high-fertility countries in Sub-Saharan Africa have a 1-in-16 lifetime risk of dying from maternal causes, compared with women in low-fertility countries in Europe, who have a 1-in- 2,000 risk, and in North America, who have a 1-in-3,500 risk of dying.
¡ Of the estimated 529,000 maternal deaths in 2000, 95 per cent occurred in Africa and Asia, while only 4 per cent (22,000) occurred in Latin America and the Caribbean, and less than one per cent (2,500) in the more developed regions of the world.
¡ Experience from successful maternal health programmes shows that much of this death and suffering could be avoided if all women had the assistance of a skilled health worker during pregnancy and delivery, and access to emergency medical care when complications arise. More...